bark, cough, wheeze kelly ussery-kronhaus, md, faafp

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

  • OverviewRespiratory disease:10% of pediatric emergency department visits20% of hospital admissions3-5% 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 ExamVital Signs: T 37.2, P 103, R 28, BP 98/55, O2 saturation 96% on RAHeight/weight/head circumference are all 25-50%ile

  • Physical Exam Physical Exam:General: NADChest: 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 perioralPhase 2: Asymptomatic period can last from minutes to months The duration of this period depends on thePhase 3:The renewed symptomatic period. Airway inflammation or infection from the foreign body will cause:Cough, wheezing, fever, sputum production, and occasionally, hemoptysis

  • ManagementIf 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

  • EPIGLOTTITISA rapidly progressive cellulitis of the of the epiglottis and surrounding structures

  • EpiglottitisClinical presentation: Symptoms:Sore throathigh feverdysphagiaRespiratory distress progresses in
  • EpiglottitisInfectious Etiologies:H. influenzae BNon-typeable H. influenzae Haemophilus parainfluenzaeS. aureusS. pneumoniae

  • Epiglottitis:Management

  • Hemophilus Influenza B (Hib)2 vaccines available1 is 3-dose series (PedvaxHIB)1 is 4-dose series (ActHIB)

    Vaccines are interchangeableIf changed at 2 or 4 months of age, need a 6-month dose of either vaccineEither 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 HibMay also prevent future ability to develop antibodies

  • PedvaxHIBHemophilus influenza type b vaccineAntigen conjugated to Meningococcal Group B outer membrane protein (PRP-OMP)2-dose primary series plus booster2, 4 months and 12-15 month boosterAlso comes in a combination vaccine with Hepatitis B (Comvax)

  • Act-HIBHemophilus influenza type b vaccineConjugated to tetanus toxoid (PRP-T)3-dose primary series plus booster2, 4, 6 months and booster at 12-15 monthsAlso comes in 2 combination vaccines With DTaP, and IPV (Pentacel) Primary seriesWith DTaP (TriHibIt) Booster dose only

  • Prevnar (PCV-7)Pneumococcal conjugate 7 valent vaccine2, 4, 6 and 12 monthsRecommended for all children 2-23 monthsGive if 24-59 months old with risk factorsNot for children >5 years oldReplaced by PCV-13 Spring 2010

  • PCV-7 PCV-13 (Prevnar13)ACIP voted 2/24/10 to replace PCV-7Transition guidelines publishedProtects against 13 instead of 7 strains Expanded vaccination for high-risk groups to 72 monthsSame dosing interval as PCV-7 for never vaccinated children

  • PCV-13High risk children include Immunocompetent children with Cyanotic congenital heart defectsChronic lung diseaseAsthma needing oral steroid treatmentDiabetesCSF leaksCochlear implantsAsplenia (congenital or acquired)Sickle cell and other hemoglobinopathies

  • PCV-13High risk children includeImmunocompromised children HIVChronic renal failureNephrotic syndromeLymphoma and leukemiaChemotherapyOrgan transplantCongenital immunodeficiencies

  • New for PCV-13Single dose for children 6-18 years old at increased risk for invasive pneumococcal diseaseGive regardless of previous PCV-7 or PPSV-23 vaccinationIncludes:Sickle cell diseaseHIV (or other immunocompromised state)Cochlear implantCSF leaks

  • croup

  • Croup management


  • Pertussis3 phases of illness (post-incubation):CatarrhalParoxysmalConvalescent

    Complications:Pneumothorax, pneumomediastinum & air in soft tissues

  • PertussisClinical presentationSymptoms:Mild to severe paroxysmal cough with dyspneaSigns:Paroxysms of coughInspiratory whoopApnea & cyanosis (infants)DiagnosisPCR or culture

  • DTaPCapital letter denotes full dose vaccineSmall a for acellularCompared to Td or TdapSmall letter denotes half dose vaccine for booster effectDiphtheria and Pertussis vaccines only given as combination with Tetanus

  • DTaP DiphtheriaTetanus Acellular pertussisPrimary series2, 4, 6 months12-18 months (at least 6 months from the 3rd dose)4 years12-14 years Tdap Then Td boosters every 10 years

  • DTaPContraindicationsSevere allergic reaction (e.g., anaphylaxis) after a previous vaccine dose or to a vaccine componentEncephalopathy (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 DTaPProgressive neurologic disorderincluding infantile spasmsuncontrolled epilepsyprogressive encephalopathy Defer DTaP until neurologic status clarified and stabilized

  • DTaPPrecautionsTemperature of >104F (>40.5C) For
  • Safe Situations to Administer DTaPTemperature of
  • Management: PertussisMonitoringCardiorespiratory monitoring Continuous pulse oximetry Apnea monitorTreatment:PRN oxygenStimulation/ suctioning Avoidance of large volume feedingsMacrolides x 14 days

  • Clinical VignetteAmy, 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 babys 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 100.4F, R42, O2 saturation 93% on RA, BP 85/55, P 180Physical Exam:General: Mild distress 2 respiratory distress, + wet coughChest: Mild intercostal retractions, scattered crackles bilaterally, and expiratory wheezes bilaterally

  • DiagnosisDiagnosis is often clinical during the RSV seasonDiagnostic testing can be done by:ImmunofluorescenceELISA

  • ManagementSupportive care Consider hospitalization:
  • 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.

  • AsthmaMost frequent respiratory diagnosis for children admitted to hospitalsCauses 5000 deaths annually in the United StatesIt is a complex syndrome consisting of inflammation which leads to: bronchospasm airwayhyperirritability

  • Asthma Triggers

    Respiratory InfectionsAllergensAirway IrritantsExerciseMedications (NSAIDS and Beta Blockers)*

  • MAJOR RISK FACTORS(at least one must be present)parental history of asthmaatopic dermatitissensitization to aeroallergens*

  • MINOR RISK FACTORS(2 required)sensitization to foodsmore than 4% eosinophiliawheezing apart from colds*

  • AeroallergenIndoor:Dust miteCockroachAnimal danderMold

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


  • Exercise Induced AsthmaCan 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*

  • Classifying Severity an Initiating Treatment: Children 0-4 years*

    Severity categoryDays and nights with symptomsInterference with normal activityexacerbationPreferred TreatmentSevere persistentThroughout (D)>1 night/wk (N)Extremely limitedSee belowStep 3:Med dose ICS and consider short course OCSModerate persistentDaily (D)3-4 nights/monthSome limitationSee belowStep 3: med dose ICS and consider short course OCSMild persistent3-6 D/wk1-2 N/monthMinor limitation2 or more/6m or >= episodes of wheezing/yr with risk factorStep 2: low dose ICSIntermittent

  • Classifying Severity and Initiating Treatment: children 5-11*

    Severity categoryDays and nights with symptomsInterference with normal activitiesPulmonary functionExacerbationsPreferred treatmentSevere persistentThroughout (D)Often (N)Extremely limitedFEV180%FEV1/FVC>80%2 or more


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