Pediatric Primary Care (61 page)

a.  Signs of moderate to severe airway obstruction.

b.  Increased work of breathing and respiratory distress.

c.  Hypoxemia.

d.  Restlessness, anxiety, or fatigue.

e.  Change in level of consciousness.

f.  Dehydration.

H.  Follow up.

1.  Call healthcare provider immediately if signs of respiratory distress increase.

2.  Increased respiratory rate.

3.  Stridor at rest.

4.  Increased retractions.

5.  Change in level of consciousness, restlessness, or anxiety.

6.  Cyanosis.

I.  Complications.

1.  Acute deterioration in respiratory status requires hospitalization/ intubation.

J.  Education.

1.  Croup usually lasts 3-7 days; typically worse at night.

2.  Give guidelines about oral intake (fluids) and urine output.

3.  Use of bathroom mist, cool night air, cool-mist vaporizer to relieve symptoms.

4.  Signs of increasing respiratory distress and hypoxemia.

5.  Good handwashing, containment of coughs/sneezes prevents spread of illness.

6.  Maintain calm, reassuring manner. Avoid situations that provoke stress or crying, which can worsen respiratory distress.

7.  Children may have repeated episodes of croup.

8.  Antibiotics are not indicated for viral croup.

9.  Avoid secondhand smoke exposure.

II. BRONCHIOLITIS

A.  Etiology.

1.  Bronchiolitis is common viral illness.

a.  RSV, bronchiolitis is most common cause of acute lower respiratory infection (LRI) in first 2 years of life.

b.  Bronchiolitis is also caused by parainfluenza 1 and 3, adenovirus, rhinoviruses, influenza, and human metapneumovirus.

2.  Transmission.

a.  Highly contagious.

•  Virus shed 5-12 days and up to 30 days with underlying disease.

•  Virus spreads by large droplet aerosols generated by coughing, sneezing.

•  Transmitted by direct contact with nasopharyngeal secretions from infected person.

i.   Virus survives on skin approximately 20 minutes.

ii.   Virus survives on gowns/tissues approximately 30-60 minutes.

iii. Virus survives on hard, nonporous surfaces approximately 6 hours.

•  High-risk factors for more severe disease: prematurity, chronic lung disease, congenital heart disease, immunosuppression.

b.  Reinfection occurs throughout life.

B.  Occurrence.

1.  Seasonal prevalence.

a.  Yearly epidemics in early winter/spring.

b.  In temperate climates, typically start in November and persist through April.

c.  Strains A and B circulated concurrently during outbreaks; strain A more dominant.

d.  By age 3, most children have been infected with RSV.

e.  Only 1-5% require hospitalization.

f.  Adolescents, adults with RSV have symptoms of upper respiratory tract infection.

C.  Clinical manifestations.

1.  Initial presentation.

a.  Mild upper respiratory infection (URI) with rhinorrhea and nasal congestion.

b.  Low-grade fever for 2-3 days.

c.  Poor appetite.

d.  Hoarse cough progresses to deep, wet cough.

•  Often paroxysmal.

•  Often associated with post-tussive vomiting.

•  Associated with wheezing.

2.  Clinical progression.

a.  LRT involvement evident by:

•  Tachypnea: 60-80 breaths/minute.

•  Dyspnea.

•  Coughing, wheezing.

b.  Neonatal presentation.

•  Lethargy, irritability.

•  Poor feeding.

•  URI symptoms.

•  Apnea: occurrence is inversely proportional to age.

D.  Physical findings.

1.  Increased work of breathing.

a.  Nasal congestion with thick purulent secretions.

b.  Respirations rapid, shallow with accessory muscle use, retractions.

c.  Nasal flaring, grunting, head bobbing.

d.  Paroxysmal cough, wheezing, crackles.

e.  Prolonged expiratory phase, chest hyperexpansion and hyperresonance.

f.  Liver and spleen may be palpable secondary to chest hyperexpansion.

g.  Hypoxemia correlates with severity of tachypnea.

h.  Paradoxical abdominal and chest wall movement.

E.  Diagnostic tests.

1.  Diagnosis often made on basis of clinical presentation, physical findings, epidemiology.

a.  Definitive diagnosis may not be necessary in infants with mild disease.

2.  Chest X-ray (CXR).

a.  Hyperinflation may be only abnormality: flattened diaphragms, increased lucency.

b.  Peribronchial thickening and increased interstitial markings.

c.  Subsegmental consolidation in upper and middle lobes: patchy atel-ectasis or consolidation due to atelectasis.

3.  Oximetry: to determine oxygenation status.

4.  Laboratory tests.

a.  Identification of virus or viral antigen in respiratory secretions.

•  Specimen obtained by nasal swab.

•  Rapid diagnostic tests detect antigen using immunofluorescence techniques or enzyme-linked immunoassays.

•  Viral culture.

F.  Differential diagnosis.