2-bronchodilator for relief of symptoms 2-bronchodilator as required + low-dose inhaled steroid Step 3: add-on therapy \200 B 2-bronchodilator as required + high-dose inhaled Short-acting steroid or Low-dose inhaled steroid +/ \200\223 long-acting bronchodilator If control is still inadequate use a trial of other therapies, e.g. leukotriene receptor an tagonist or slow release theophylline Step 4: persistent poor control B \200 2-bronchodilator as required + high-dose inhaled Short-acting steroid (up to 800micrograms/day) + long-acting bronchodilator or Theophylline s or ipratropium +/ \200\223 alternate day steroid Step 5: continuous or frequent use of oral steroid \200 \200 \200 Use daily steroid tablet in lowest dose Maintain high-dose inhaled steroid at 800micrograms /day Refer to respiratory specialist 09_McClure_09.indd 267 11/14/2012 2:34:56 PM CHAPTER 9 Respiratory medicine 268 Asthma: clinic management (2) 0 \200\2232yrs In this age group, a spacer device with an app ropriate face mask is used, e.g. a small volume Aerochamber or Ablespacer which can tak e any inhaler; or a large volume Volumatic or Nebuhaler , which only \201 t cer- tain inhalers. Prophylactic therapy with inhaled steroids is more effective than cromoglicate. Acute treatment \200 \200 \200 : <2400micrograms/day (in 6 doses). : <6000micrograms/day (in 6 doses). : <480microgr ams/day (in 4 doses). Salbutamol via Volumatic Terbutaline via Nebuhaler Ipratropium via Volumatic Prophylactic treatment \200 \200 : 100 \200\223400micrograms/day. Budesonide via Nebuhaler Beclometasone via Volumatic : 100 \200\223400micrograms/day. 3 \200\2235yrs Acute treatment \200 \200 : <3600micrograms/day (in 6 doses). : <6000micrograms/day (in 6 doses). Salbutamol via Volumatic Terbutaline via Nebuhaler Prophylactic treatment \200 \200 \200 \200 : 100 \200\223800micrograms/day. Budesonide via Nebuhaler Beclomethasone via Volumatic Fluticasone via Volumatic Salmeterol via Volumatic given alone and only when the child is also taking an inhaled steroid. Combin ation inhaler: salmeterol). : 100 \200\223800micrograms/day. : (>4yrs) 100 \200\223200micrograms/day : (>4yrs) 50micrograms/day. Must never be Seretide (contains \201 xed doses of \202 uticasone and 5 \200\22312yrs Acute treatment \200 \200 \200 : <7200micrograms/day (in 6 doses). Salbutamol Accuhaler Salbutamol inhaler: (>12 years) <7200micrograms/day (in 6 doses). Terb utaline inhaler: (>12 years) <7200micrograms/day (in 6 doses). Prophylactic treatment \200 \200 \200 \200 : 100 \200\223800micrograms/day. Budesonide Turbohaler Beclometasone via Accuhaler Fluticasone via Volumatic Combination inh aler \200\223 Seretide and salmeterol); or Symbicort turbohaler ( \201 xed doses of bud esonide and formoterol). : 100 \200\223800micrograms/day. : 100 \200\223400micrograms/day. (contains \201 xed doses of \202 uticasone 09_McClure_09.indd 268 11/14/2012 2:34:56 PM ASTHMA: CLINIC MANAGEMENT (2) 269 Useful clinic guides Steroids \200 Fluticasone and budesonide are preferable since they have fewer side-effects than beclometa sone Patients on doses of steroids greater than \202 uticasone 500micrograms/day, budeson ide 800micrograms/day, beclometasone 800micrograms/day should be under the supervision of a specialist clinic Long-acting \200 2-agonists Salmeterol may be of value for night-time symptoms or daytime activity Should be used as a prophylactic agent Consider in patients on inhaled beclometasone or budesonide 400microgram s/day, or \202 uticasone 200micrograms/day \200 Allergen avoidance \200 \200 \200 \200 Removal of feather or woolen bedding Wrapping of mattress in plastic Cleaning of carpets an d furniture No pets in the house if the child is allergic to them Passive smoking \200 \200 No smoking in the house or car. Parents/carers must be strongly encouraged to stop smoking completely. Education Older patients will need to learn more about their condition and how it is best t reated. For example: \200 \200 \200 \200 \200 Which medication to use and when Best inhaler technique What to do if asthma is getting wor se Not to smoke Gargle after steroid inhaler use so as to avoid oral thrush 09_McClure_09.indd 269 11/14/2012 2:34:56 PM CHAPTER 9 Respiratory medicine 270 Cystic \201 brosis Cystic \201 brosis (CF) is an autosomal recessive genetic disorder l eading to a defect in the CF transmembrane receptor (CFTR) protein, which results in defect ive ion transportation in exocrine glands. In the lung abnormal sodium and chloride ion tra nsportation causes thickening of respiratory mucus. The lung is therefore prone to inadequa te mucociliary clearance, chronic bac- terial infection, and lung injury. There are also si milar effects \200\224although not with superadded infection \200\224in other organs that l ead to pancreatic insuf \201 ciency, liver disease, and, in the male, infertility. There a re over 1500 mutations in the CFTR gene; the most common is the ZF508 deletion. CF is the m ost common genetic disease in Caucasions (1/2500). Diagnosis Screening Since 2007 in the UK all newborn babies are screened for cystic \201 brosis looking for an abnormally raised immunoreactive trypsinogen (IRT) and 29 CFTR gene m utations from blood-spot analysis on the Guthrie card. History Give particular attention to: \200 \200 \200 \200 \200 \200 Cough and wheeze. Shortness of breath. Sputum production. Haemoptysis. Stool type (e.g. fat ty, oily, pale) and frequency. Weight loss or poor weight gain. About 10 \200\22320% of CF patients present in the neonatal period with meco- nium ileus. H owever, most children with CF present with: \200 \200 \200 malabsorption; failure to thrive; recurrent chest infection. Examination Full assessment of: \200 \200 \200 respiratory system; liver and GI system; growth and development. Investigations \200 \200 Sweat test showing increased chloride levels (>60mmol/L). CXR: dilatation, cysts, linear sh adows, and in \201 ltrates. Lung function: lung volumes. hyperin \202 ation, increased antero-posterior diameter, bronchial obstructive pattern with decreased FVC and increased 09_McClure_09.indd 270 11/14/2012 2:34:56 PM CYSTIC FIBROSIS: PROBLEMS 271 Cystic \201 brosis: problems Lifelong therapy and supervision are required in CF. There i s a variety of problems that can be expected at different ages. Infancy \200 \200 \200 b p.862). Meconium ileus ( Neonatal jaundice (prolonged). Hypoproteinaemia and oedema. Childhood \200 \200 \200 \200 \200 \200 Recurrent lower respiratory tract infections. Bronchiectasis (occasionally) Poor appetite. Rectal prolapse ( Nasal polyps. Sinusitis (rare to have symptoms). b p.871). Adolescence \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 Bronchiectasis. Diabetes mellitus ( Cirrhosis and portal hypertension. Distal intestinal ob struction ( Pneumothorax. Haemoptysis. Allergic bronchopulmonary aspergillosis. Male infert ility. Arthropathy. Psychological problems. b p.406). b p.274). 09_McClure_09.indd 271 11/14/2012 2:34:56 PM CHAPTER 9 Respiratory medicine 272 Cystic \201 brosis: management (1) The management of the child with CF requires close co- operation be- tween local hospitals and regional centers. Patients and their families gain much from expert clinics, and from other patients and their families. Effective management requires a multidisciplinary team approach, which should include: \200 \200 \200 \200 \200 \200 \200 pediatric pulmonologist; physiotherapist; dietician; nurse liaison or practitioner in CF; p rimary care team; teacher; psychologist. All patients with CF should have a thorough annual multisystem review. Table 9.1 summarizes the range of information that is needed. You will \201 nd following these parameters hel pful when assessing progression, deteriora- tion, and need for supraregional referral for h eart \200\223lung transplantation. 09_McClure_09.indd 272 11/14/2012 2:34:56 PM CYSTIC FIBROSIS: MANAGEMENT (1) 273 Table 9.1 Information needed for the annual multisystem review of a CF patient Blood tests Hematology FBC, clotting (APTT, PTT) Biochemistry Cr, U, Na, K, Cl, HCO3 (Mg, Ca if on IV colistin), iron studies, vitamin A, D & E levels Liver function ALP, alanine transferase (ALT), bilirubin, albumin, protein Glucose control Random glucose, HbA1c, oral glucose tolerance test (>10yrs) Immunology IgE, IgG, RAST to aspergillus, pseudomonas precipitins Radiology X-rays Chest US Liver and bowel Dual-energy X-ray absorptiometry (DEXA) scan Consider in children >10yrs, or those on increasing doses of steroids, or those who have in creasing fractures Lung function Measurements FEV1, FVC, PEFR, residual volume (RV), TLC esting SpO2 Oximetry Bacteriology Sputum/cough swab Cultures including Burkholderia cepacia, acid-fast bacilli Morbidity Hospital Number of admissions and days in hospital Chest Number of courses of IV antibiotics Reviews Medications Requirements (dose) Physiotherapy Technique, education, equipment Nutrition Education, enzymes, supplements Social Family support, genetics, housing, school, statement of special needs Psychology Is an assessment needed? 09_McClure_09.indd 273 11/14/2012 2:34:56 PM CHAPTER 9 Respiratory medicine 274 Cystic \201 brosis: management (2) Pulmonary care Physiotherapy All children with CF shou ld have physiotherapy at least twice a day. Parents and older children are taught how to do some of the following: \200 \200 \200 \200 \200 chest percussion; postural drainage; self-percussion; deep breathing exercises; use of \202 utter or acapello device. Antimicrobial therapy Most experts recommend antibiotic therapy. \200 Oral during periods when well: against Haemophilus in \202 uenzae. IV for acute exacerbations: initially cour ses of antibiotics can be administered via an indwelling long-line that should last a numbe r of weeks if needed. However, as infections become more frequent, a permanent form of IV a ccess (such as an indwelling Portacath) will help. Nebulized for those chronically infected with Staphylococcus aureus and Pseudomonas aeruginosa. Other therapies \200 \200 \200 Annual in \202 uenza immunization. Bronchodilators for those with reversible airway obstru ction. Mucolytics: hypertonic (7%) saline used before physiotherapy. Oral azithromycin (lon g-term anti-in \202 ammatory). recombinant DNAase 2hr before physiotherapy; or inhaled Gastrointestinal management Distal intestinal obstruction (meconium ileus equivalent) \200 \200 Lactulose: Oral acetylcysteine solution: and 30mL in >7-yr-olds. Treatment doses are double to three times this amount. : oral dose can be used as a single treatment dose (50mL Gas trogra \201 n for children 15 \200\22325kg, and 100mL for those >25kg). Fluid intake shoul d be encouraged for 3hr after administering the Gastrogra \201 n . 1mL/kg/day. prophylaxis 15mL of 10%/day in <7-yr-olds Nutrition \200 Pancreatic insuf \201 ciency: supplements (Creon ) taken with all meals and snacks. Ranit idine or omeprazole may be useful if the response to enzymes is unsatisfactory. High-calori e diet: children with CF require 120 \200\223150% of normal energy intake. Salt supplements : salt depletion is a risk in CF patients during the \201 rst year of life, and in the su mmer months in older patients. In exceptionally hot weather supplements include 500mg/day d uring the \201 rst year, 1g/day in <7-yr-olds, and 2 \200\2234g/day in >7-yr-olds. treated with oral enteric-coated pancreatic 09_McClure_09.indd 274 11/14/2012 2:34:56 PM CYSTIC FIBROSIS: MANAGEMENT (2) 275 Fat-soluble vitamin supplements \200 \200 \200 Dalivit drops 1mL/day or multivitamin tablets. Multivitamins: Vitamin E: Vitamin K: abnormal clotting). 50mg/day if <1yr; 100mg/day 1 \200\22316yrs. if there is evidence of liver disease (hepatos plenomegaly or 09_McClure_09.indd 275 11/14/2012 2:34:56 PM CHAPTER 9 Respiratory medicine 276 Chronic lung disease of prematurity See also b pp.166 \200\223167. As the quality and outcome of neonatal intensive care for premature babies has improved, mo re and more infants with chronic lung disease (CLD) are being seen. There are a variety of lung conditions that affect premature babies and necessitate mechanical ventilation; these are dis- cussed in Chapter 6, b p.107. \200 \200 b p.150). Respiratory distress syndrome ( b p.152). Neonatal pneumonia ( The following can affect newborn of any gestational age: \200 \200 \200 \200 \200 \200 b p.152). b p.852). Meconium aspiration ( Diaphragmatic hernia ( Pulmonary hypoplasia. Alveolar capillary membr ane dysplasia. Interstitial lung disease. Surfactant protein de \201 ciency. On follow-up in the pediatric clinic you may see oxygen-dependency due to any of these cond itions. CLD in this context is de \201 ned as abnormal CXR and use of supplementary oxygen beyond 28 days. Management In many respects the approach to managing oxygen-dependent infants with compromi sed lung function is very similar to caring for infants with CF. A multisystem and multidis ciplinary team approach is needed. This should include home and community liaison \200\224t he neonatal unit nurse spe- cialist and health visitor are particularly helpful. Nutritional support and therapy \200 Weight problem with inadequate intake, consult a dietician for advice. Gastrostomy: Gastro- oesophageal lung hyperin \202 ation, and tachypnoea promote the development of vomiting an d GOR. The lungs need to be protected and adequate feeding needs to be ensured. Initially t ry medical therapy (see Chapter 10, b p.326). If these measures fail, fundoplication and ga strostomy feeds are required. Vitamins: thriving well (i.e. vitamin compound drops, folic a cid, iron). gain and growth: these should be monitored and, if there is a \200 procedure sometimes required to enable full feeding. re \202 ux (GOR): the \200\230 \202 at \200\231 position of the diaphragm, appropriate vitamin supplements are used until the child is Antimicrobial therapy \200 Vaccination: steroids may be at risk if given live or attenuated immunization (e.g. BCG, mu mps, measles, and rubella (MMR)). Antibiotics: viral illness may result in signi \201 cant deterioration in CLD. Take sputum, throat swab, and nasopharyngeal aspirate for viral and bacterial cultures. Have a low threshold for using antibiotics. all immunizations should be up-to-date. Children on 09_McClure_09.indd 276 11/14/2012 2:34:56 PM CHRONIC LUNG DISEASE OF PREMATURITY 277 Antivirals: syncytial virus bronchiolitis although its bene \201 t is controversial. Patie nts should have had prophylaxis (see b p.288). aerosolized ribavirin may be required for severe respiratory Obstructive airway disease Wheeze is a common symptom in infants with CLD. Asthma treatment s are often used in these children. Oxygen therapy The ultimate aim of supervision of these patients is to withdraw oxygen in a safe and timely manner. The target oxygen saturation (SpO2) in patients on supplemental ox ygen via nasal cannulae is (cid:2)92%. Withdrawal is appro- priate when the infant is clini cally well, gaining weight, and has an SpO2 consistently above 92% with an oxygen requireme nt (cid:1)0.1L/min. Children can be weaned from continuous low \202 ow oxygen to night-ti me and naps only, or remain in continuous oxygen throughout the 24hr until the child has no requirement at all. Oxygen equipment should be left in the home for at least 3mths after t he child has stopped using it. If this is in a winter period, it is usually left until the end of winter. 09_McClure_09.indd 277 11/14/2012 2:34:57 PM CHAPTER 9 Respiratory medicine 278 Congenital respiratory tract disorders The following congenital abnormalities of the upper and lower airway are discussed in Chapter 23, b p.843. Congenital abnormalities of the upper airway \200 \200 \200 \200 \200 b p.846). b p.846). Choanal atresia ( Laryngeal atresia ( Cleft lip and palate ( Pierre \200\223Robin sequence ( Tracheo-oesophageal \201 stula ( b p.846). b p.847). b pp.848 \200\223849). Congenital abnormalities of the lower airways \200 \200 \200 \200 \200 b p.851). Congenital cystic adenomatoid malformation ( Sequestration ( Congenital lobar emphysema ( C ongenital diaphragmatic hernia ( Hiatus hernia ( b p.851). b p.851). b p.852). b p.852). 09_McClure_09.indd 278 11/14/2012 2:34:57 PM SLEEP APNOEA 279 Sleep apnoea Apnoea is de \201 ned as a lack of breathing. Obstructive apnoea refers to a lack of air \202 ow in the face of respiratory effort. It is most often associated with sl eep. The obstructive sleep apnoea syndrome (OSAS) may be due to tonsillar/adenoidal hypetro phy, macroglossia, or micrognathia. Diagnosis History \200 \200 \200 \200 Examination (see also b p.31) A thorough exam ination is needed: \200 Snoring and sleep disturbance. Daytime sleepiness or inattention. Eneuresis. Only about 15% of snoring children have signi \201 cant airway obstruction. Symptoms of upper airway obstruction and OSAS are more likely to be due to adenoidal hypert rophy, rather than just tonsillar hypertrophy. Middle ear infection and chronic effusion: w ith adenoidal hypertrophy. Mouth breathing leading to dry mouth and cracked lips. these are features associated Investigation A thorough history and examination should identify children who need further treatment. However, there is a place for the following as part of an assessment. \200 Sleep study: this could include just overnight pulse oximetry, but to diagnose impaired gas exchange transcutaneous CO2 measurement is necessary as well. Sometimes more extensive pol ysomnography may be needed, mainly to differentiate obstructive from central causes of slee p apnoea Chest consequences of airway obstruction. X-ray and ECG: to examine for s right heart cardiac Treatment Surgery is indicated when the following criteria are met. Tonsillectomy Any of: \200 \200 Airway obstruction (usually performed with adenoidectomy). History of recurrent tonsillitis (>7 episodes in 1yr, or >10 episodes in 2yrs). History of two episodes of peritonsillar ab scess. Adenoidectomy Any of: \200 \200 \200 \200 Airway obstruction. Recurrent or chronic middle ear infection. Recurrent or chronic nasopha ryngitis. Chronic mouth breathing. 09_McClure_09.indd 279 11/14/2012 2:34:57 PM CHAPTER 9 Respiratory medicine 280 Allergic rhinitis Up to 20% of the population have symptoms of allergic rhinitis, which inc lude nasal congestion, itching, sneezing, and discharge. Diagnosis History \200 \200 Identify seasonality of the symptoms and history of atopy. Take a history of environmental exposures such as parental smoking, pets, dust mite, stuffed toys, carpet, bedding, etc. Examination Check for: \200 \200 \200 \200 \200 \200 mouth breathing; postnasal drip; cough; nose rubbing; suborbital venous congestion; watery- red eyes. Investigation \200 \200 Skin tests for speci \201 c antigens. Speci \201 c serum IgE measurements. Treatment Allergen avoidance \200 \200 Dust covers on bedding. Avoid stuffed toys. Symptom relief \200 \200 \200 Antihistamines. Montelukast. Intranasal steroids. 09_McClure_09.indd 280 11/14/2012 2:34:57 PM ALLERGIC RHINITIS 281 09_McClure_09.indd 281 11/14/2012 2:34:57 PM CHAPTER 9 Respiratory medicine 282 Upper airway infections Ear, sinus, nose, and throat infections account for 80% of respirat ory infec- tions. The diagnosis URTI may mean any of the following. \200 Common and respiratory syncytial virus (although latter more often causes acute bronchiolit is). throat (pharyngitis and tonsillitis): pharyngitis is usually due to Sore viral infecti on with adenovirus, enterovirus, and rhinovirus. Bacterial infection with group A B-haemoly tic streptococcus may be present in the older child. Tonsillitis associated with purulent e xudates may be due to group A B-haemolytic streptococcus or the Epstein \200\223Barr virus (EBV) (see also b pp.707, 711). infection (acute otitis media): common pathogens include vi ruses, Ear pneumococcus, group A B-haemolytic streptococcus, Haemophilus in \202 uenzae, a nd Moraxella catarrhalis (see also b p.900). Sinusitis may occur with viral or bacterial in fection. cold (coryza): commonly due to rhinoviruses, coronaviruses, Diagnosis History Children often present with a combination of: \200 \200 \200 \200 \200 \200 Painful Fever Blocked Nasal Earache . (in children with asthma there may be an exacerbation ). Wheeze throat. (which may even induce febrile convulsions). nose (which may lead to feeding dif \201 culty in infants). discharge. Examination A thorough examination is needed. In infants you will need to make sure that th ere is not a serious infection and, in those with dif \201 culty feeding because of blocke d nose, that feeding will be adequate. In older children you will need to check for possibl e bacterial infection and give antibiotics when the following are identi \201 ed. \200 think of otitis media if there is discharge, if the tympanic Ears: membrane is not intact, if the eardrums are bright red and bulging with loss of norma l light re \202 ection. Neck: lymphadenopathy. Pharynx: tonsils. think of bacterial throat infection if there is tender cervical think of tonsillitis if there are purulent exudates on in \202 amed Treatment Symptom relief \200 \200 Fever: Earache: use paracetamol or ibuprofen. use paracetamol or ibuprofen. 09_McClure_09.indd 282 11/14/2012 2:34:57 PM UPPER AIRWAY INFECTIONS 283 Antibiotics Virus infection causes the majority of URTIs and antibiotics should not be pres cribed. However, if bacterial tonsillitis, or pharyngitis due to group A B-haemolytic strep tococcus, or acute otitis media is suspected, then they should be given after a throat swab has been taken for bacterial culture. A positive culture will mean that a 10-day course of antibiotics is required. \200 Tonsillitis maculopapular rash in cases of EBV infection. Use penicillin V, or erythromycin in allergic patients, for 10 days. Acute otitis media: co-amoxiclav will cover the common causes of otitis media and be effective against B-lactamase-producing H. in \202 uenzae an d M. catarrhalis. and pharyngitis: avoid amoxicillin because it may cause 09_McClure_09.indd 283 11/14/2012 2:34:57 PM CHAPTER 9 Respiratory medicine 284 Laryngeal and tracheal in \202 ammation There are a number of laryngeal and tracheal cause s of in \202 ammation and airway obstruction. In the acute setting you will be concerned w ith three common conditions. \200 Viral laryngotracheobronchitis (croup): mucosal in \202 ammation affecting anywhere from t he nose to the lower airway that is commonly due to parain \202 uenza, in \202 uenza, and respiratory syncytial virus in children aged 6mths to 6yrs. Spasmodic airways with no appa rent respiratory tract symptoms. Acute epiglottitis: life-threatening swelling of the epigl ottis and septicaemia due to Haemophilus in \202 uenzae type b infection \200\224most comm only in children aged 1 \200\2236yrs. This is now rare since routine HiB immunization. or recurrent croup: barking cough and hyperreactive upper Diagnosis History In practice the two main conditions that require differentiating are vira l croup and acute epiglottitis. The history may help in this process (see Table 9.2). Examination Do not examine the throat. Take a careful assessment of severity including: \200 \200 \200 \200 \200 Degree of stridor and subcostal recession. Respiratory rate. HR. LOC (drowsiness), tirednes s, and exhaustion. Pulse oximetry. Table 9.2 Differentiating between viral croup and acute epiglottitis Croup Epiglottitis Time course Days Hours Prodrome Coryza None Cough Barking Slight if any Feeding Can drink No Mouth Closed Drooling saliva Toxic No <38.5*C Rasping Yes >38.5*C Soft Fever Stridor Voice Hoarse Weak or silent 09_McClure_09.indd 284 11/14/2012 2:34:57 PM LARYNGEAL AND TRACHEAL INFLAMMATION 285 Treatment Priority The main priority in the emergency setting is to differentiate between a cute epiglottitis and viral croup (see Table 9.2). If you are unsure, stabilize the child a nd ensure that nothing precipitates distress and possible airway obstruction. Try and keep the child, family, and staff calm. Alert emergency otolaryngologist and anesthetist to the possibility of a need for emergen- cy airway support. Viral croup Children with mild illness can be managed at home, but advise parents that if t here is recession and stridor at rest then they will need to return to hospital. Infants <1 2mths may need closer attention. Treatments include the following. \200 or humidi \201 ed air: although widely used to ease breathing the Moist bene \201 t of these physical measures is unproven. Steroids: (0.15mg/kg stat dose) or nebulized budesonide (2mg stat dose) reduces the severity and duration of croup. They ar e also likely to reduce the need for endotracheal intubation. Nebulized symptoms. oral prednisolone (2mg/kg for 3 days) or oral dexamethasone adrenaline (epinephrine): can provide transient relief of In cases that require endotracheal intubation steroids should be given and, if there is evi dence of secondary bacterial infection or bacterial tracheitis, antibiotics should be added . Acute epiglottitis The child with acute epiglottitis will need to be managed in the intensi ve care unit after endotracheal intubation. Once this procedure has been completed take blo od cultures and start IV antibiotics. \200 2nd cefotaxime) IV for 7 \200\22310 days. Rifampicin or 3rd generation cephalosporin (e.g. cefuroxime, ceftriaxome, or prophylaxis to close contacts. 09_McClure_09.indd 285 11/14/2012 2:34:57 PM CHAPTER 9 Respiratory medicine 286 Bronchial disease The main symptoms of acute bronchitis in children are cough and fever. Tw o infections \200\224Bordetella pertussis and Mycoplasma pneumoniae \200\224may produce sym ptoms that persist for a number of weeks. Another condition often diagnosed in infants with out fever or distress is \200\230wheezy bronchitis \200\231, or \200\230recurrent bronchi tis \200\231. This condition has been the topic of much de- bate over the years as to wheth er these infants have asthma or not, and whether they should be treated as such. Whooping cough Bordetella pertussis infection typically induces three stages of illness: \200 mild symptoms with fever, cough, and coryza. \200 (2 \200\2236wks): severe paroxysm al cough, followed by inspiratory Catarrhal (1 \200\2232wks): Paroxysmal whoop and vomiting. Convalescent month to resolve. (2 \200\2234wks): lessening symptoms that may take a whole A whooping cough-like syndrome may be caused by Bordetella parapertus- sis, Mycoplasma pneu moniae, Chlamydia, or adenovirus. History There may be a typical history. In young infants, however, whoop is often absent, a nd apnoea is a more common \201 nding. In older children, and par- ents, there may be a h istory of persistent and irritating cough. Examination and investigation A thorough examination is needed. In infants you will need to make sure that the problem is not pneumonia. Also, check the following: \200 \200 \200 \200 Eyes: subconjunctival hemorrhages are common. CXR . Blood Pernasal count: leucocytosis and lymphocytosis. swab: culture of Bordetella pertussis. Treatment Hospital care \200 admission is required for those with a history of apnoea, In fants: cyanosis, or signi \201 cant paroxysms. Close monitoring is required particularly i n infants since there is a risk of seizures, encephalopathy, and death. Isolation: with ant ibiotics. patients should be isolated for 5 days after starting treatment Contacts \200 Immunization: close contact if they are not protected. Immunization reduces the risk of an individual developing infection by 90%, but the level of protection declines steadily throu gh childhood. Prophylactic recommended for children <7yrs who have been in antibiotics: should be given to close contacts. Antibiotics Erythromycin for 14 days (or clarithromycin for 7 days) to reduce infectivity b ut this may have minimal effect on the cough. 09_McClure_09.indd 286 11/14/2012 2:34:57 PM BRONCHIAL DISEASE 287 09_McClure_09.indd 287 11/14/2012 2:34:57 PM CHAPTER 9 Respiratory medicine 288 Bronchiolitis Bronchiolitis, most commonly due to respiratory syncytial virus (RSV), affect s everyone by the age of 2yrs. Whether you meet this infection in your \201 rst winter, o r your second, determines how ill you will be. RSV invades the nasopharyngeal epithelium an d spreads to the lower airways where it causes increased mucus production, desquamation, an d then bronchiolar obstruction. The net effect is pulmonary hyperin \202 ation and atelect asis. The other causes of bronchiolitis include infection with para- in \202 uenza, in \202 uenza, adenovirus, rhinovirus, metapneumovirus, chlamydia, and Mycoplasma pneumoniae. There is an increased risk of severe infection in infants with CHD, CLD of prematurity, immunode \201 ciency, and other lung disease. Diagnosis History In winter months infants with a typical history will have had coryza, fol - lowed by a dry cough, followed by worsening breathlessness. Other fea- tures in the histo ry include: \200 \200 \200 wheeze; feeding dif \201 culty; episodes of apnoea. Rarely, other presenting histories in babies include: \200 \200 encephalopathy with seizures due to hyponatraemia; apnoea and near miss sudden infant death . Examination and investigation A thorough examination is needed in order to assess the degre e of res- piratory distress: \200 \200 \200 \200 \200 \200 \200 \200 cyanosis or pallor; dry cough; tachypnoea; subcostal and intercostal recession; chest hyper in \202 ation; prolonged expiration; pauses in breathing or apnoea; wheeze and crackles. Key investigations include: \200 \200 \200 Pulse oximetry: CXR: Nasopharyngeal swab: binding. to assess oxygenation. to assess hyperin \202 ation, atelectasis, and consolidation. immuno \202 uorescent antibody testing for RSV 09_McClure_09.indd 288 11/14/2012 2:34:57 PM BRONCHIOLITIS 289 Hospital treatment The treatment of RSV bronchiolitis is mainly supportive and includes: \200 \200 \200 Oxygen to achieve pulse oximetry saturation >92%. If tachypnoea, limit oral feeds and use a NGT. Bronchodilators for wheeze: nebulized salbutamol, ipratropium, and adrenaline have al l been used in studies. The best evidence is for nebulized adrenaline. Mechanical ventilati on for severe respiratory distress or apnoea. Antiviral therapy with ribavirin should be reserved for immunode \201 cient patients and t hose with underlying heart or lung disease, although its ben- e \201 t is uncertain. Prophylaxis Palivizumab is a monoclonal antibody to RSV and can be used as prophy- laxis. P reterm babies and oxygen-dependent infants at risk of RSV infec- tion can receive a monthly IM injection (for 5mths starting in October) to reduce risk of hospitalization and the nee d for mechanical ventilation. Follow-up Recurrent cough, wheeze, and tachypnoea may occur after RSV infection. These may require treatment and are best assessed in outpatients. Daily oral montelukast granules can sometimes help reduce the symptoms. A proportion of patients may develop asthma \200\224th ey may have been predis- posed to develop this problem irrespective of RSV in early infancy . 09_McClure_09.indd 289 11/14/2012 2:34:57 PM CHAPTER 9 Respiratory medicine 290 Pneumonia Pneumonia is an infection of the lower respiratory tract and lung paren- chyma th at leads to consolidation. Viruses alone account for 14 \200\22335% of all community acquir ed pneumonia in childhood. In 20 \200\22360% of children a pathogen is not found. Common in fecting bacterial agents by age are: \200 Neonates: Staphylococcus aureus. Infants: School streptococcus, Bordetella pertussis, Mycop lasma pneumoniae. group B streptococcus, Escherichia coli, Klebsiella, \200 Streptoccus pneumoniae, Chlamydia. age: Streptococcus pneumoniae, Staphylococcus aureus, gr oup A Certain groups of children are at risk of pneumonia, e.g. those with: \200 \200 \200 \200 \200 \200 congenital lung cysts; chronic lung disease ( immunode \201 ciency ( cystic \201 brosis ( sickle cell disease ( tracheostomy b p.276); b pp.295, 724); b p.270); b p.620); in situ. Diagnosis History The patient may have had a recent URTI and may also be complaining of ple uritic chest pain or abdominal pain. The typical history will have: \200 \200 \200 (cid:2)38.5*C; temperature shortness of breath; cough; with sputum production in older children ( >7yrs). Examination Check for the following: \200 Signs use of accessory muscles for breathing. A resting respiratory rate of 70breaths/min i n infants or >50breaths/min in children indicates severe illness. Desaturation every child admitted to hospital with pneumonia. SpO2 \211 92% in room air indicates severe illness. h ealth and lethargy. General Auscultation decreased breath sounds; tactile vocal fremitus; b ronchial breathing. of respiratory distress: tachypnoea; grunting; intercostal recession; and cyanosis: pulse oximetry should be performed in \200 signs of lobar pneumonia: dullness to percussion; crackles; Investigations The investigations that help in diagnosis include: \200 \200 \200 culture may be of limited value. Sputum: Nasopharyngeal Blood: pneumonia (not necessary in community-acquired pneumonia). CX R: Pleural \202 uid: when there is a signi \201 cant pleural effusion, an aspirated samp le should be sent for culture and antigen testing once a drain is inserted. aspirate: viral immuno \202 uorescence in infants. culture should be done in all children with severe bacterial \200 not as routine (see b p.291). 09_McClure_09.indd 290 11/14/2012 2:34:57 PM PNEUMONIA 291 Viral titres: save a sample of blood for acute titre testing, which can be assayed the same time as the convalescent sample if a microbiological diagnosis is not made. See Box 9.2 for summary of investigations. Chest X-ray There are a variety of changes ranging from lobar consolidation to the mere pre sence of patchy bilateral in \201 ltrates. In general, routine CXR is not needed in childr en with mild uncomplicated LRTI. In other cases, look for pleural effusions, \202 uid lev els, apparent round pneumonia, cavitation, hilar adenopathy, and any calci \201 cation. At follow-up, patients with history of signi \201 cant acute X-ray change (e.g. lobar collap se, apparent round pneu- monia, empyema) or continuing symptoms will require repeat X-ray. Box 9.2 Investigations to consider in children with chronic or recurrent pneumonia Step 1: initial blood tests \200 \200 Hematology: Immunology: response to immunizations (tetanus and pneumococcus), rheumatoid fa ctor Antibodies: Genetics: FBC, complement screen, ESR IgA, IgE (and aspergillus RAST), IgG, IgM, antibody \200 aspergillus precipitins, antinuclear antibodies CF genotype Step 2: other tests \200 test \200 \200 \200 Sweat Microbiology: Lung Radiology: sputum culture function: spirometry, lung volumes, and reversibility CXR, barium swallow for vascular ring, sinus radiography Step 3: further investigations \200 Hematology: subsets, and cellular immune function Imaging: pH study: Video \202 uoroscopy : Nasal ciliary there is a normal nasal nitric oxide) Bronchoscopy: microbiological sample collection neutrophil and monocyte function, lymphocyte \200 \200 \200 high resolution CT scan of the chest for gastro-oesophageal re \202 ux for silent aspiration biopsy: microscopy and function (may be unnecessary if visualization of dynamic airway function, as well as 09_McClure_09.indd 291 11/14/2012 2:34:57 PM CHAPTER 9 Respiratory medicine 292 Pneumonia: treatment Oral antibiotics are safe and effective in the treatment of community- acquired pneumonia. IV antibiotics are used in children who cannot absorb oral antibiotics or in those with severe symptoms. The speci \201 c choice of antibiotic is based on the f ollowing: \200 \200 \200 \200 \200 Age of the child. Host factors. Severity of illness. Information about cultures if known. C XR \201 ndings if known. Antibiotic therapy for pneumonia Under 5yrs Streptococcus pneumoniae is the most likely pathogen. The causes of atypical pne umonia are Mycoplasma pneumoniae and Chlamydia tracho- matis \200 \200 First-line Alternatives: erythromycin, clarithromycin, or azithromycin for atypical pneumon ia treatment: amoxicillin co-amoxiclav or cefaclor for typical pneumonia; Over 5yrs Mycoplasma pneumoniae is more common in this age group \200 First-line treatment: amoxicillin is effective against the majority of pathogens, but consi der macrolide antibiotics if mycoplasma or chlamydia is suspected Alternatives: macrolide, or a combination of \202 ucloxacillin with amoxicillin if Staphylococcus aureus is suspected consider using a Severe pneumonia Co-amoxiclav, cefotaxime, or cefuroxime IV Supportive therapies Consider whether any of the following are needed: \200 IV \200 \200 Antipyretics for fever. \202 uids: consider if dehydrated or not drinking. Supplemental so that SpO2 is maintained >92% (b p.46). Chest oxygen: administer oxygen via headbox or nasal cannulae drain: for \202 uid or pus collections in the chest, as in empyema. Physiotherapy Chest physiotherapy is generally not bene \201 cial in children with pneumon ia and should not be performed. 09_McClure_09.indd 292 11/14/2012 2:34:58 PM PNEUMONIA: EFFUSION, EMPYEMA 293 Pneumonia: effusion, empyema The presence, in association with pneumonia, of a small effusi on that does not cause any respiratory distress can be managed conservatively without the n eed for aspirating a sample. A \202 uid sample, however, is needed if there is: \200 \200 \200 \200 \200 a large effusion; no clear underlying diagnosis; respiratory distress; persistent fever des pite antibiotic treatment; long history (>14 days). Fluid sample After US of the chest and checking blood-clotting studies, a small chest drain (or pigtail drain) should be inserted into the pleural \202 uid unless effu- sion is sma ll. Samples should be sent for the following: \200 \200 Microbiology: Cytology: cell types. Cytology for lymphoma may give false \200\223ve result in up to 10% of cases. bacterial culture and sensitivity, acidfast bacilli. presence of pus cells and microscopic assessment of aberrant Diagnosis of empyema The diagnosis of empyema can be based on the presence of: \200 \200 Fluid: US scan: pH < 7.2, glucose <3.3mmol/L, protein >3g/L, pus cells. loculation or \201 brin strands seen. Fluid drainage After inserting the small-bore drain or pigtail catheter, \202 uid should be allowed to drain into standard commercially available systems (e.g. water- seal two-bott le system). The drain can be removed if draining <50mL in 24hrs. Urokinase for empyema In empyema, as opposed to simple pleural effusion, instillation of ur oki- nase via the chest drain is recommended. \200 