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Acute respiratory tract infections

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Acute respiratory tract infections

  1. 1. ACUTE RESPIRATORY TRACT INFECTIONS (ARI) Dr. Yordanos G(MD) For Anesthesia 2nd yr students 4/28/2018 1
  2. 2. GENERAL CONSIDERATIONS  Acute respiratory infection (ARI) is the leading cause of morbidity and mortality in children under 5years of age.  ARI accounts for about 28% of under 5 mortality in Ethiopia.  ARI involves both upper and lower respiratory tract infections  Nearly 20% of ARI develop acute lower respiratory tract infections, mainly pneumonia. 4/28/2018ARI 2
  3. 3. RISK FACTORS FOR ARI  Pollution  lack of breast feeding  Congenital abnormalities heart or Lung  Immuno deficiency  Malnutrition  Young infants  Poor socio-economic status 4/28/2018ARI 3
  4. 4. ANATOMIC CLASSIFICATION OF AIRWAY  Upper Airway all structures/ the part of air way above thoracic inlet,  Supraglottic area(nasopharynx, epiglottis, larynx, aryepiglottic folds, and false vocal cords)  Glottic and subglottic area (extends from the vocal cords to the extra thoracic segment of the trachea)  Lower Airway –  Intrathoracic trachea and into the lungs  intrathoracic-extrapulmonary airway extends from the thoracic inlet to the main stem bronchi  the intrapulmonary airway is within the lung parenchyma 4/28/2018ARI 4 Upper Airway Lower Airways
  5. 5. UPPER RESPIRATORY TRACT INFECTIONS 1. Acute Pharyngitis - refers to inflammation of the pharynx, including erythema,edema, exudates, or enanthem (ulcers, vesicles) 4/28/2018 5
  6. 6. COMMON ETIOLOGIES Viruses Bacterial Adenovirus Coronavirus Cytomegalovirus Epstein-Barr Enteroviruses Herpes simplex virus Human immunodeficiency virus Human metapneumovirus Influenza viruses Measles virus Parainfluenza viruses Respiratory syncytial virus Rhinoviruses Streptococcus pyogenes (Group A streptococcus) Arcanobacterium haemolyticum Fusobacterium necrophorum Corynebacterium diphtheriae Neisseria gonorrhoeae Group C streptococci Group G streptococci Francisella tularensis Chlamydophila pneumoniae Chlamydia trachomatis Mycoplasma pneumoniae 4/28/2018 6
  7. 7. GROUP A STREPTOCOCCUS EPIDEMIOLOGY  Strept. Pharyngitis uncommon before 2-3yrs, has a peak incidence in the early school years, and declines in late adolescence and adulthood  Peaks during winter and spring  Group C strept. and Arcanobacterium- haemolyticum are causes in adults. 4/28/2018 7
  8. 8. PATHOGENESIS OF ACUTE PHARYNGITIS  Major virulent factor of GABHS is the M-protein  Type specific immunity develops and provides protection from subsequent infection by the same M-type.  Scarlet fever is caused by GABHS that produce one of the three streptococcal pyrogenic exotoxins(SPE)-A,B,C.  SPE-A is mostly(strongly) associated.  Infection with one clade confers immunity to the same clade & hence infection can occur up to three times. 4/28/2018 8
  9. 9. CLINICAL MANIFESTATIONS OF ACUTE PHARYNGITIS  Rapid onset with prominent sore throat & fever  Headache and GI symptoms are common  Pharynx is red &tonsils are enlarged & classically covered with yellow blood tinged exudates  Doughnut lesions or petechae on the soft palate and posterior pharynx  Uvula is red and swollen  Tender and swollen ant. Cervical nodes  Some may manifest with Scarlet fever-circumoral pallor, strawberry tongue &red and finely papular rash that feels like sandpaper & with goose pimples 4/28/2018 9
  10. 10. CONT……  Onset of viral pharyngitis has more insidious onset  Adeno virus(pharyngoconjuctival fever)  Coxakie virus-herpangina1-2mm grayish vesicles and punched out ulcers in the posterior pharynx /acute lymphonodular pharyngitis3-6mm yellowish white nodules on post. Pharynx.  EBV has systemic manifestations as part of infectious mononucleosis syndrome  HSV- high grade fever and gingivostomatitis 4/28/2018 10
  11. 11. DIAGNOSIS  Throat culture and rapid antigen-detection tests (RADTs) are the diagnostic tests for GAS available in routine clinical care.  Throat culture is un imperfect gold standard for Dx of GABHS pharyngitis (high false –ve and false +ve)  Rapid test(less sensitive and highly specific) ,If +ve – treat and - ve(strong clinical ground)- throat culture 4/28/2018 11
  12. 12. MANAGEMENT  nonspecific, symptomatic therapy can be an important part of the overall treatment plan( with anti-pyretics,analgesics,local anesthetics) • Antibiotic therapy should be started immediately without culture for children with symptomatic pharyngitis and a positive rapid streptococcal antigen test, a clinical diagnosis of scarlet fever, a household contact with documented streptococcal pharyngitis, a past history of acute rheumatic fever, or a recent history of acute rheumatic fever in a family member  Penicillin v or amoxicillin for 10 days  Erythromycin (if allergic to the above drugs)  Clindamycin and Azithromycin clear carriers 4/28/2018 12
  13. 13. RECURRENT PHARYNGITIS  Recurrent streptococcal pharyngitis can represent : - relapse with an identical strain if type-specific antibody has not yet developed. - Poor compliance  If GABHS is detected by repeat culture a few days after completing treatment, therapy to eliminate carriage is recommended.  Prolonged pharyngitis (>1-2 wk) suggests another disorder such as neutropenia or recurrent fever syndromes,autoimmune diseases.  Tonsillectomy lowers the incidence of pharyngitis for 1-2 yr among children with recurrent episodes  culture-positive GABHS pharyngitis that has been severe and frequent (>7 episodes in the previous year, or >5 in each of the preceding 2 yror ≥3 in each of the previous 3 yr) 4/28/2018 13
  14. 14. COMPLICATION OF PHARYNGITIS:  Otitis media  Local suppurative complications like parapharyngial abscess  ARF and AGN  Poststreptococcal reactive arthritis 4/28/2018 14
  15. 15. 2. RETROPHARYNGEAL AND PARA PHARYNGEAL ABSCESS  Neck contains deeply located LNs including retro &lateral pharyngeal nodes w/c drain the upper air way &digestive tract  Retropharyngeal space is located between the pharynx & the cervical vertebrae extending down to superior mediastinum.  Lateral pharyngeal space is bounded by pharynx medially carotid sheath posteriorly & muscles of styloid process laterally.  The two spaces communicate with each other.  Infection usually extends from infection of oropharnyx  Once infected, the nodes progress through 3 stages cellulitis,phlegmon and abscess 4/28/2018 15
  16. 16. ETIOLOGIES  Usually polymicrobial  Usual pathogens include group A strept., oropharyngeal anaerobes and S.aures  Hib, klebsiella andMycobacterium avium- intracellulare( MAI) are other causes EPIDIMIOLOGY  Common b/n 3-4yrs of age  Males are affected more than females  Rare after 5yrs b/c retropharyngeal nodes involute at this age 4/28/2018 16
  17. 17. Retropharyngeal cellulites or abscess results from:-  oropharygeal infection  dental infection  vertebral osteomyelitis  Trauma to the oropharynx 4/28/2018 17
  18. 18. CLINICAL MANIFESTATIONS Retropharyngeal abscess  Fever,irritability,decreased oral intake and drooling of saliva  Neck stiffness,tortocolis &refusal to move the neck  Muffled voice,stridor and respiratory distress  Bulging of posterior pharyngeal wall  Cervical adenopathy may be present Lateral pharyngeal abscess  Fever,dysphagia &prominent bulge on the lateral pharyngeal wall  Sometimes there is medial displacement of tonsils 4/28/2018 18
  19. 19. INVESTIGATIONS  Culture from the pus  CT  X-ray(wide retropharyngeal space >1/2 the thickness of adjoining vertebrae 4/28/2018 19
  20. 20. Differential Dx  epiglottis  Foreign body aspiration  Meningitis  Lymphoma  Hematoma  Vertebral osteomyelitis 4/28/2018 20
  21. 21. MANAGEMENT IV Abcs with or without drainage  Cephalosporine plus Ampicillin-Sulbactam or Chloramphenicol  Clindamycin/cloxacillin  50% of Pts do not need drainage Indications for drainage  obstruction  failure to respond to IV Abcs 4/28/2018 21
  22. 22. CONT….. COMPLICATIONS  Upper air way obstruction  Rupture leading to aspiration pneumonia  Mediastinitis  Thrombophlebitis of internal jugular vein(Lemierre Ds)  Lemierre syndrome is a serious complication of F. necrophorum pharyngitis and is characterized by  septic thrombophlebitis of the internal jugular veins with  septic pulmonary emboli,  producing hypoxia and pulmonary infiltrates  Erosion of carotid artery sheath 4/28/2018 22
  23. 23. 3. PERITONSILLAR ABSCESS  More common than deep neck infections  Caused by invasion through the capsule of the tonsils ETIOLOGY  Group A strept,mixed oropharyngeal anaerobes Clinical manifestation  An adolescent with a recent history of acute pharyngotonsillitis  Sore,fever,trismus &dysphagia  Asymmetric tonsillar bulge with displacement of uvula (this is diagnostic) INVESTIGATION  CT is helpful for revealing the abscess  Culture from the pus 4/28/2018 23
  24. 24. MANAGEMENT  Surgical drainage & Abcs  Surgical drainage could be accomplished via Needle aspiration(resolution in 95%)  5% who fail after aspiration require incision and drainage  Indications for tonsillectomy  Failure to improve after 24hrs  Recurrent abscess or tonsillitis  Complications COMPLICATIONS  Feared complication is rupture and aspiration pneumonia  There is 10% risk of recurrence 4/28/2018 24
  25. 25. 4.CROUP(LARYNGEOTRACHEOBRONCH ITIS)  An acute respiratory illness characterized by - distinctive barking cough, hoarseness, and inspiratory stridor in a young child, usually between 6 months and 3 years old.  This syndrome results from inflammation of varying levels of the upper respiratory tract, which sometimes spreads to the lower respiratory tract, producing concomitant lower respiratory tract findings.  Croup is primarily laryngotracheitis, and encompasses a spectrum of infections from laryngitis to laryngotracheobronchitis and sometimes laryngotracheobronchopneumonitis. 4/28/2018 25
  26. 26. CROUP(LARYNGEOTRACHEOBRON CHITIS)  Minor reduction in cross sectional area due to mucosal edema or other inflammatory processes cause an exponential increase in air way resistance  The cricoid cartilage defines the narrowest portion of the upper air way in a child<10yrs 4/28/2018 26 ADULT INFANT
  27. 27. ETIOLOGY  Para influenza virus(types 1,2,3)-75% of cases  Influenza(A &B),adenovirus,RSV&measles  Rarely mycoplasma pneumonae EPIDEMIOLOGY  Age -3 months – 5years  Peak is in the second year of life  Males are more frequently affected  Common in winter  Recurrence common till 3-6yrs and decreases with age  15 %have strong family history of croup 4/28/2018 27
  28. 28. Clinical manifestation  Most common cause of upper resp. tract obstruction  Pts usually have rhinorrhea,pharyngitis,mild cough &low grade fever  Symptoms are worse at night  Sms resolve with in a week  Other Fx members may have mild resp. illness INVESTIGATIONS  PA chest X-ray steeple sign or inverted pencil sign  Laryngoscope-erythematous edema with destruction of mucosal epithelium 4/28/2018 28
  29. 29. RADIOGRAPH OF AN AIRWAY OF A PATIENT WITH CROUP, SHOWING TYPICAL SUBGLOTTIC NARROWING (STEEPLE SIGN). 4/28/2018 29
  30. 30. CROUP SCORING SYSTEM:WESTLEY  Level of consciousness: Normal, including sleep = 0; disoriented = 5  Cyanosis: None = 0; with agitation = 4; at rest = 5  Stridor: None = 0; with agitation = 1; at rest = 2  Air entry: Normal = 0; decreased = 1; markedly decreased = 2  Retractions: None = 0; mild = 1; moderate = 2; severe = 3 4/28/2018 30
  31. 31. CONT……  Mild croup is defined by a Westley croup score of ≤2  Moderate croup is defined by a Westley croup score of 3 to 7  Severe croup is defined by a Westley croup score of ≥8 4/28/2018 31
  32. 32. MANAGEMENT Mild croup _ home management  Moderate to sever croup needs admission for Mx  Steam therapy  Dexamethasone  Nebulized epinephrine  Humidified Oxygen  Fluid  Artificial air way -Tracheostomy Complications:  Otitis media  Bacterial trachitis  Pneumonia 4/28/2018 32
  33. 33. 6. EPIGLOTITIS  Life threatening infection  HIB is the most common cause Clinical manifestation  Sudden on set  Rapidly progressing respiratory obstruction  Fever, Toxicity, sore throat  Voice/cry - muffled  Soft stridor  Drooling of saliva  Hyper extended neck 4/28/2018 33
  34. 34. CONT… Diagnosis:  Clinical with out throat examination  Blood culture  Lateral cervical X-ray “thumb sign’’→→  Never use spatula to examine"epiglottis  Large *cherry red* epiglottis (laryngoscope) 4/28/2018 34
  35. 35. MANAGEMENT Precaution  Do not manipulate the throat  Do not put patient in supine positions  Do not send for X-ray  Do not put on steam in halation, steroid or epinephrine  Maintenance IV fluid  IV CAF/ Ampicilin/cephalosporins  Endotracheal intubation  Tracheostomy 4/28/2018 35
  36. 36. 7. BACTERIAL TRACHEITIS  Bacterial tracheitis is an acute bacterial infection of the upper airway that is potentially life threatening.  Staphylococcus aureus is the most commonly isolated pathogen. Moraxella catarrhalis, nontypable H. influenzae, and anaerobic organisms have also been implicated.  The mean age is between 5 and 7 yr.  Incidence and severity do not differ by sex.  Bacterial tracheitis often follows a viral respiratory infection (especially laryngotracheitis), so it may be considered a bacterial complication of a viral disease, rather than a primary bacterial illness.  This life-threatening entity is more common than epiglottitis in vaccinated populations 4/28/2018 36
  37. 37. CONT… Clinical Manifestations  Typically, brassy cough  High fever and “toxicity” with respiratory distress can occur immediately or after a few days of apparent improvement.  The patient can lie flat, does not drool, and does not have the dysphagia associated with epiglottitis.  The usual treatment for croup (racemic epinephrine) is ineffective.  Intubation or tracheostomy may be necessary, but only 50-60% of patients require intubation for management; younger patients are more likely to need intubation.. 4/28/2018 37
  38. 38. CONT….  The major pathologic feature appears to be mucosal swelling at the level of the cricoid cartilage, complicated by copious, thick, purulent secretions, sometimes causing pseudomembranes.  The diagnosis is based on evidence of bacterial upper airway disease, which includes high fever, purulent airway secretions, and an absence of the classic findings of epiglottitis. X-rays are not needed but can show the classic findings  purulent material is noted below the cords during endotracheal intubation 4/28/2018 38
  39. 39. LATERAL RADIOGRAPH OF THE NECK OF A PATIENT WITH BACTERIAL TRACHEITIS, SHOWING PSEUDOMEMBRANE DETACHMENT IN THE TRACHEA. (FROM STROUD RH, FRIEDMAN NR: AN UPDATE ON INFLAMMATORY DISORDERS OF THE PEDIATRIC AIRWAY: EPIGLOTTITIS, CROUP, AND TRACHEITIS, AM J OTOLARYNGOL 22:268–275, 2001. PHOTO COURTESY OF THE DEPARTMENT OF RADIOLOGY, UNIVERSITY OF TEXAS MEDICAL BRANCH AT GALVESTON.) 4/28/2018 39 Thick tracheal membranes seen on rigid bronchoscopy. The supraglottis was normal. A, Thick adherent membranous secretions. B, The distal tracheobronchial tree is unremarkable. In contrast to croup, tenacious secretions are seen throughout the trachea, and in contrast to bronchitis, the bronchi are not affected
  40. 40. MANAGEMENT  Current empiric therapy recommendations for life- threatening infections such as bacterial tracheitis include vancomycin and a β-lactamase–resistant β- lactam antimicrobial agent (e.g., naficillin or oxacillin).  an artificial airway should be strongly considered.  Supplemental oxygen is usually necessary 4/28/2018 40
  41. 41. 4/28/2018 41
  42. 42. LOWER RESPIRATORY TRACT INFECTIONS • Community Acquired pneumonia • Bronchiolitis 4/28/2018 42
  43. 43. 1.BRONCHIOLITIS  Infection can cause obstruction to flow by internal narrowing of the airways  Bronchiolitis is the most common acute viral lower respiratory tract illness occurring during the first 2 years of life  More common in 1-3months age  is predominantly a viral disease.  RSV is responsible for more than 50% of cases. Other agents include parainfluenza,adenovirus, rhinovirus, and Mycoplasma. 4/28/2018 43
  44. 44. RISK FACTORS  boys,  in those who have not been breastfed,  crowded conditions.  mothers who smoked during pregnancy The following children are at risk to develop severe brochiolitis  Age <12 wk,  preterm birth, or  underlying comorbidity such as cardiovascular,pulmonary, neurologic, or immunologic disease. 4/28/2018 44
  45. 45. PATHOPHYSIOLOGY  characterized by bronchiolar obstruction with edema, mucus, and cellular debris.  resistance is inversely proportional to the 4th power of the radius of the bronchiolar passage.  radius of an airway is smaller during expiration, early air trapping and overinflation. complete obstruction, atelectasis. 4/28/2018 45
  46. 46. CLINICAL MANIFESTATIONS  Symptoms of URTI  fever(low grade)  Cough, Poor feeding, tachypenia  Wheezing, signs of distress, cyanosis  Apnea may be more prominent early in the course of the disease in young infants (<2 mo old) or former premature infants. 4/28/2018 46
  47. 47. CONT…… Differential diagnosis • Bronchial asthma  Broncho pneumonia  CHF  Congenital malformations  Foreign body aspiration  Gastroesophageal reflux 4/28/2018 47
  48. 48. DIAGNOSIS  clinical,  CXR can reveal hyperinflated lungs with patchy atelectasis  The white blood cell and differential counts are usually normal.  PCR and radioimmunoassays 4/28/2018 48
  49. 49. MANAGEMNET Mainly supportive  humidified Oxygen  Fluid  Bronchodilators????? Antibiotics- only if there is bacterial superinfection 4/28/2018 49
  50. 50. PROGNOSIS  1st 48-72 hr after onset of cough and dyspnea; air hunger, apnea, and respiratory acidosis.  Median duration of symptoms is around 14 days  Recurrent wheezing among most children, the episodes diminish or disappear before reaching teenage years  4/28/2018 50
  51. 51. 2.PNEUMONIA  Pneumonia, defined as inflammation of the lung parenchyma,  is the leading cause of death globally among children younger than age 5 yr, accounting for an estimated 1.2 million (18% total) deaths annually 4/28/2018 51
  52. 52. CLASSIFICATION  Based on the anatomic or radiologic distribution - Lobar pneumonia - multilobar(bronchopneumonia) - interstial pneumonia • Based on the setting of acqusition of the infection - community acquired pneumonia - Hospital acquired pneumonia 4/28/2018 52
  53. 53. RISK FACTORS  Lung diseases-asthma, cystic fibrosis  Anatomic abnormalities-TEF, cleft palate  GERD-recurrent aspiration  Neurologic disorders- loss of consciousness, neuromuscular disorders  Immunodeficiency states- HIV, malnutrition, steroid therapy…  CHF-VSD, AV canal defect  Viral respiratory tract infection  Lack of immunization  Trauma, anesthesia, and aspiration. 4/28/2018 53
  54. 54. ETIOLOGIC AGENTS Neonates Age<5yrs Older childeren(>5yrs) •GBS • Gram negatives-E.coli, klebsella, Pseudomonas • S. aureous •Listeria monocytogens Viral(most common) - RSV -influenza,parainfluenza - adenovirus Bacterial - S.pneumoniae -HIB -Chlamydia -S.aures S. pneumonia Mycoplasma 4/28/2018 54
  55. 55. PHYSIOLOGIC DEFENSE MECHANISMS  Mucociliary clearance  Secretory immunoglobulin A (IgA)  Coughing  Alveolar and bronchioles macrophages 4/28/2018 55
  56. 56. PATHOGENESIS  Viral pneumonia ,spread of infection along the airways, accompanied by direct injury of the respiratory epithelium, which results in airway obstruction from swelling, abnormal secretions, and cellular debris  Atelectasis, interstitial edema, and ventilation-perfusion mismatch causing significant hypoxemia often accompany airway obstruction.  Viral infection of the respiratory tract can also predispose to secondary bacterial infection by disturbing normal host defense mechanisms, altering secretions, and modifying the bacterial flora. 4/28/2018 56
  57. 57. CONT…..  In bacterial pneumonia organisms colonize the trachea and subsequently gain access to the lungs  pneumonia may also result from direct seeding of lung tissue after bacteremia. When bacterial infection is established in the lung parenchyma  M. pneumoniae – direct injury of airway epithelium  S. pneumoniae -characteristic focal lobar involvement.  Group A streptococcus - interstitial pneumonia  S. aureus -confluent bronchopneumonia pneumatoceles, empyema 4/28/2018 57
  58. 58. CONT…..  Recurrent pneumonia is defined as 2 or more episodes in a single year or 3 or more episodes ever, with radiographic clearing between occurrences. An underlying disorder should be considered if a child experiences recurrent pneumonia 4/28/2018 58
  59. 59. CLINICAL MANIFESTATIONS Preceding URTI followed by Cough, fast breathing, and Fever -Grunting, lethargy -Tachypnea -Chest recession -Crepitation/ Bronchial breath sounds, -Dullness, signs of effusion 4/28/2018 59
  60. 60. CONT… Severe pneumonia:  fast breathing (Tacypnea) + chest indrowing and grunting HOSPITALIZATION OF CHILDREN WITH PNEUMONIA  Age <6 mo  Sickle cell anemia with acute chest syndrome  Multiple lobe involvement  Immunocompromised state  Toxic appearance  Moderate to severe respiratory distress  Complicated pneumonia*  Dehydration  Vomiting or inability to tolerate oral fluids or medications  No response to appropriate oral antibiotic therapy  Social factors (e.g., inability of caregivers to administer medications  at home or follow-up appropriately) 4/28/2018 60
  61. 61. DIAGNOSIS - Clinical -CBC-leukocytosis -CXR- infiltrations -consolidation -pneumatocele -pleural effusion -Sputum (gram stain, AFB) - Pleural fluid analysis- -Blood culture 4/28/2018 61
  62. 62. RADIOGRAPHIC FINDINGS CHARACTERISTIC OF PNEUMOCOCCAL PNEUMONIA IN A 14 YR OLD BOY WITH COUGH AND FEVER. POSTEROANTERIOR (A) AND LATERAL (B) CHEST RADIOGRAPHS REVEAL CONSOLIDATION IN THE RIGHT LOWER LOBE, STRONGLY SUGGESTING BACTERIAL PNEUMONIA 4/28/2018 62
  63. 63. TREATMENT  Treatment of suspected bacterial pneumonia is based on the presumptive cause and the age and clinical appearance of the child  Out patient Mx: - high doses of amoxicillin (80-90 mg/kg/24 h other alternatives are augementin for 5-7 days. 4/28/2018 63
  64. 64. INPATIENT MANAGEMENT • Neonate – Ampicillin +Gentamycine  Children _ Crystalin penicillin +/- chloramphenicol antibiotic sensitivity pattern and causative agent known:  Streptococcus-penicillin, Ceftriaxone, vancomycin  Staphylococcus- Cloxacillin ,vancomycin, Cephalosporin (1st Gen.)  H.influenza-Chloramphenicol, Cephalosporin  Gram negative organisms -Aminoglycosids, Cephalosporin -If the patient is not improving after 24-48 hrs, shift to second line 4/28/2018 64
  65. 65. Complications-  parapneumonic effusion  Empyema/pyopneumothorax  Lung abscess  pericarditis/myocarditis  Septicemia  Septic arthritis/Osteomylitis  Meningitis 4/28/2018 65
  66. 66. TRANSUDATE EMPYEMA Appearance Clear Cloudy or purulent Cell count (per mm3) <1000 Often >50,000 (cell count has limited predictive value) Cell type Lymphocytes, monocytes Polymorphonuclear leukocytes (neutrophils) Lactate dehydrogenase <200 U/L >1000 U/L Pleural fluid/serum LDH ratio <0.6 >0.6 Protein >3g Unusual Common Pleural fluid/serum protein ratio <0.5 >0.5 Glucose* Normal Low (<40 mg/dL) pH* Normal (7.40-7.60) <7.10 Gram stain Negative Occasionally positive (less than one- third of cases) 66
  67. 67. TREATMENT OF COMPLICATIONS Empyema- depends on the stage(exudative, fibrinopurulent, organizing).  Antibiotics 4-6wks  Chest tube drainage  Chest physiotherapy Lung abscess-  Braod spectrum antibiotics anaerobic coverage, 4-6wks  Postural drainage, chest physiotherapy 4/28/2018 67
  68. 68. PREVENTION • Vaccination PCV10 vaccine.  has reduced the incidence of pneumonia hospitalizations.  The expansion of influenza vaccine recommendations to include all children >6 mo of age might be expected to affect pneumonia hospitalization rates in a similar fashion, and ongoing surveillance is warranted 4/28/2018 68
  69. 69. FOREIGN BODY ASPIRATION EPIDEMIOLOGY AND ETIOLOGY  Choking is a leading cause of morbidity and mortality among children,especially those younger than age 4 yr  Children, younger than 3 yr of age, account for 73% of cases.  The most common objects that children choke on are food, coins, balloons, and toys.  One-third of aspirated objects are nuts, particularly peanuts. Fragments of raw carrot, apple, dried beans, popcorn, and sunflower or watermelon seeds are also aspirated, as are small toys or toy parts. 4/28/2018 69
  70. 70.  The majority of aspirated foreign bodies in children are located in the bronchi (right bronchus in 58%of the cases ) . Laryngeal and tracheal foreign bodies are less common. 4/28/2018 70
  71. 71. CLINICAL MANIFESTATIONS  Has 3 stages: 1.Initial event: Violent paroxysms of coughing, choking, gagging, and possibly airway obstruction occur immediately when the foreign body is aspirated. 2.Asymptomatic interval: foreign body dislodges and the immediate irritating sympt subside. accounts for a large percentageof delayed diagnoses and overlooked foreign bodies.  3. Complications: Obstruction, erosion, or infection develops; fever, cough, hemoptysis, pneumonia, and atelectasis. 4/28/2018 71
  72. 72. CONT…..  Choking or coughing episodes accompanied by new onset wheezing are highly suggestive of an airway foreign body.  Physician should specifically inquire about nuts since it is the most common foreign body  The signs and symptoms of FBA vary according to the location of the FB  laryngotracheal FBs typically present with acute respiratory distress, stridor, hoarseness, increased respiratory effort, or complete airway obstruction, which must be addressed promptly 4/28/2018 72
  73. 73. CONT….  Bronchial foreign bodies are the most common. The usual symptoms are coughing and wheezing; hemoptysis, dyspnea, choking, shortness of breath, respiratory distress, decreased breath sounds, fever, and cyanosis may also occur  Tracheal foreign bodies are rare. Symptoms of a tracheal foreign body include stridor, wheeze, and dyspnea. 4/28/2018 73
  74. 74. DIAGNOSIS  A witnessed episode of choking: defined as the sudden onset of cough and/or dyspnea and/or cyanosis in a previously healthy child, has a sensitivity of 76 to 92 percent for the diagnosis of FBA. CXR:  most aspirated objects are radiolucent so may nt be helpful  common radiographic findings in lower airway FBA are hyperinflated lung, 4/28/2018 74
  75. 75. MANAGEMENT If there is complete airway obstruction: -back blows ,chest compressions in infants, and the Heimlich maneuver in older children, should be attempted • Bronchoscopy • Antibiotic and corticosteroids if the foreign body has been retained for longer period 4/28/2018 75
  76. 76. COMPLICATIONS  Air trapping  Atelectasis  Postobstrucive pneumonia  bronchiectasis 4/28/2018 76
  77. 77. PREVENTION  Hard and/or round foods should not be offered to children younger than four years of age  Children should be taught to chew their food well;  Coins and other small items should not be given to young children as rewards…… 4/28/2018 77
  78. 78. 4/28/2018 78

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