UpperLower Respiratory Tract Infection

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Upper/Lower Respiratory Tract Infection

• Marie - Martine Logvinoff, MD

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Epiglottitis (Supraglottitis)

• Acute fulminant inflammation and edema of the
  epiglottis, aryepiglottic folds and surrounding
  tissue, usually caused by Haemophilus Influenza
  type b (G-bacillus), (GABS, S. pneumo, Staph)
• 2 - 6 years
• sudden onset, rapid course often progressing to
  complete respiratory obstruction (high fever,
  toxic, muffled speech, sitting forward)
• Diagnosis
• History
• Lateral Neck Radiograph (see protocol)
  thumbprint
• Therapy
• Intubation by experienced personnel
• 2nd, 3rd generation cephalosporins
• Do not attempt to examine the pharynx
• Do not place the child supine for procedure

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Laryngotracheobronchitis (LTB or subglottic
croup)

• Acute inflammation and edema of the subglottic
  larynx, trachea, and bronchi
• Parainfluenza 1, 2, 3 gt RSV gt Influenza gt Adeno
  Virus
• Spasmodic croup year-round in pre-school
  children, at night
• 3m 3y
• URI for several days, followed by inspiratory
  Stridor and barking cough, hoarse cry, worse at
  night
• Male
• A.P neck
• Usually self-limited may recur
• Therapy Supportive
• (IV fluids, cool mist, racemic epinephrine,
  steroid)
• If severe obstruction O2 intubation (6)

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Stridor

• Harsh, whistling sound generated during
  inspiration
• Maximum over the extrathoracic airway
• Pitch dependent on the degree of obstruction

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Differentiating Features of Supraglottic and
Subglottic Disorders
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Bacterial Tracheitis

• Laryngeal Diphtheria disappeared.
• Recognized in 1915 after Influenza epidemic
• Non diphteric bacterial infection in children
• JAMA, 1978 Bacterial Tracheitis in 8 patients,
  as a uncommon URI, but life- threatening.

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Bacterial Tracheitis, Cont.

• Symptoms of URI,
• then cough, retraction, stridor
• hoarseness, toxicity and fever.
• Diagnosis bronchoscopymucosal swelling,
  
• thick secretion.
• Mortality 18 40
• respiratory failure pneumonia
• ARDS Toxic Shock

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Changing Epidemiology of Life- Threatening Upper
Airway Infection

• Reemergence of bacterial tracheites
• (Pediatrics 1182006)
• Vermont Children Hospital 1997
  2006(admissions)
• n107 - Viral Group
• (16 or 15 in ICU 3 intubations)
• n 18 Bacterial Tracheitis
• (17 or 94 in ICU-15 intubations)
• n 2 Epiglotittis
  (Adolescents no HIB vaccine)
• Non classic GAS
• Non Typable H.Infl.

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Vermont Study

• 18 cases (94 ICU) 83 Intubated
• Culture
• 6/15 Staph.aureus .
• 5/15 Influenza virus.
• Other moraxella, non typable H.Influ.

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Conclusion

• Immunization against HIB.
• Use of corticosteroid for viral croup
• Has made Bacterial Tracheitis 3 times more likely
  to cause an acute life threatening upper airway
  infection.

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Differential Diagnosis of Stridor/Upper Airway
Obstruction
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Differential Diagnosis of Stridor

• ACUTE
• Acute Laryngotracheobronchitis (LTB, viral croup)
• Acute Epiglottitis
• Foreign Body
• Diphtheria
• Retropharyngeal Abscess
• Trauma
• Allergic
• Peritonsillar abscess Severe Tonsillitis

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CHRONIC

• Laryngeal
• 1. Laryngomalacia (Infantile
• Larynx)
• 2. Hemangioma
• 3. Laryngeal web, cleft
• 4. Cyst
• 5. Papilloma
• 6. Rickets
• 7. Unilateral or bilateral
• vocal cord paralysis
• 8. Subglottic Stenosis
• 9. Foreign body
• 10. Allergy

• B. Tracheal
• 1. Vascular Ring
• 2. Tracheomalacia
• 3. Foreign Body
• C. Epiglottis
• 1. Cyst (dermoid,
  aryepiglottic, thyroglossal duct)
• 2. Floppy Epiglottis

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Pediatric Pneumonia

• Children
• The majority are VIRAL
• RSV
• Parainfluenza
• Influenza
• Bacterial
• Streptococcus pneumonia
• Streptococcus pyogenes
• Staphylococcus aureus
• Haemophilus influenzae
• Chlamydia trachomitis
• Mycoplasma pneumoniae
• Mycobacterium tuberculosis

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Viruses that Cause Upper and Lower Respiratory
Tract Infections
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Neonate

• Acquired at home or in the hospital
• Physical
• Classic signs
• Tachypnea, retraction, nasal flowing, fever, coup
• Non-specific signs may be present
• Apnea, anorexia, lethargy, vomiting

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Pneumonia in the newborn, in the hospital

• Streptococcus Group B (GBS)
• Escherichia coli
• TORCH agent
• Klebsiella pn.
• Staphylococcus aureus
• RSV (during outbreak)

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Bronchiolitis

• Most common lower respiratory infection during
  the first 2 years of life
• Inflammation of the bronchioles (small airways)
  usually the result of a viral illness
• RSV most common agent 50-70 (epidemic)
• Parainfluenza (1-3)
• Influenza, Adenovirus, Enterovirus
• Characterized by
• Rapid breathing
• Chest retraction
• Wheezing
• Management
• Supportive (nasal suction, O2, hydration)
• Hospitalization
• RSV monoclonal antibody

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Physical Exam

• Respiratory rate (asleep or at rest)
• Auscultation
• Breath sounds
• Normal
• Bronchial
• Decreased
• Adventitious sounds
• Wheezing
• Crackles
• Other clinical clues
• Cough (paroxymal)
• Conjuctivitis
• Skin (vesicles, petechiae, rash
• Exposure, travel

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Diagnostic Workup of Pneumonia
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Radiographic Clues of Respiratory Infection

• Bilateral hyperinflation
• Viral
• Lobar consolidation
• Bacterial
• Hilar adenopathy
• MTB
• Fungal
• Lymphoma

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Radiographic Clues

• Pneumotocele
• Staphylococcus aureus
• Hydrocarbon pneumonia
• Interstitial
• G (-) bacteria
• Viral, pneumocystis carinii
• Pleural fluid
• Bacterial (Staphyl., H. inf., Strep. pneumo.,
  TB), malignancy

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Sputum culture

• Value ?
• Gram stain
• Abundance of neutrophils (25 LPF)
• Absence of squamous cells
• Heavy preponderance of a specific organism
• Culture
• Heavy growth of one type of bacteria

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• Naso-pharyngeal culture and throat culture
• are of no help
• are misleading

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Chlamydia Trachomitis

• Obligate intracellular parasite venerally
  transmitted most common form of pneumonia in
  infants lt6m
• Age 1-3 months of age
• Afebrile
• 40 conjuctivitis
• Cough

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Chlamydia Trachomitis cont

• Lab Eosinophilia (400 / mm3 )
• Specific IgM ? 132
• X-ray non-specific viral pneumonitis
• Giemsa stain of tracheal secretion cytoplasmic
  inclusion bodies
• DFA staining from conjunctiva/pharynx cells
• Rx Erythromycin 40 mg/kg/d 2 weeks

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