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ACUTE RESPIRATORY INFECTIONS OF THE UPPER RESPIRATORY TRACT IN CHILDREN. ACUTE BRONCHITIS. 1. SIGNIFICANCE Bronchitis is the most common disease of childhood next to indigestion and diarrhoea. It is especially prevalent in children who are just starting to mix with other children at playgroup or nursery school. They have no in-built immunity till then to all the infections they are likely to contact for the first time. And, so, coughs, colds and bronchitis can occur with monotonous regularity in this age group, particularly in allergic children 2. PREREQUISITES The skills listed below will not be taught in this lesson but are necessary to perform physical examination of the patient practical training. Therefore, before beginning this lesson, one has to be sure of the ability to: Inspect the thorax and its respiratory movements and note rate, rhythm, depth, and effort of breathing; Inspect for retractions of the supraclavicular areas of contractions of the sternomastoid muscles on respiration; Observe shape of child`s chest; Palpate the chest for respiratory expansion, tactile fremitus; Percuss the chest in the standard areas, comparing one side with the other at each level; Auscultate the chest with stethoscope in order to evaluate breath sounds. 3. EDUCATIONAL OBJECTIVES Student should know: - theetiology, pathogenesis, clinical manifestation, differencial diagnosis and treatment for the most common acute respiratory infections of the upper respiratory tract in children, acute bronchitis and bronchiolitis. Student should be able: - to identify the child with the most common acute respiratory infections of the upper respiratory tract in children, acute bronchitis and bronchiolitis, make correct decisions during physical examination of the patients, take appropriate actions based on those decisions, demonstrate skills to develop management and follow up measures. 4. INTERDISCIPLINARY INTEGRATION Discipline Normal anatomy, Physiology Student should know Anatomic and physiologic features of the respiratory system in children of different age groups Biochemistry Normal ranges for the routine biochemical blood analysis Student should be able to Use knowledge of anatomic and physiologic features of the respiratory system in children for evaluation of clinical findings Assess blood biochemistry and comment on deviations from normal in a clinical context Congenital pulmonary lymphangiectasia Children with pulmonary venous obstruction or severe pulmonary lymphangiectasia present with dyspnea and cyanosis in the newborn period. Chest radiographs reveal diffuse, dense, reticular densities with prominence of Kerley B lines. If the lung is not completely involved, the spared areas appear hyperlucent. Respiration is compromised because of impaired diffusion and decreased pulmonary compliance. The diagnosis can be suggested by CT scan and cardiac catheterization; definitive diagnosis requires lung biopsy (either thoracoscopic or open). Pathology Histologic and histochemical presentation of the respiratory tract illnesses in children Pathologic physiology Pathophysiologic mechanisms of the respiratory failure Sampling of sputum, pleural excudate, blood for bacterial cultures Physical examination of the respiratory system in children. Correct performance of pulmonary tests. Microbiology Propedeutics of pediatric diseases Imaging studies Intensive care Indications and methods of imaging studies in respiratory tract illnesses Symptoms and signs of respiratory failure of different stages, its etiology, and principles of intensive care Use knowledge of histologic and histochemical presentation of the respiratory tract illnesses in children for evaluation of clinical findings Recognize symptom and signs of respiratory failure Assess microbiologic findings in clinical context Perform physical examination of the respiratory system (gross inspection, palpation, percussion, auscultation), Assess the results of pulmonary tests Assess radiologic examination of the chest Recognize respiratory failure, assess its severity, provide emergency care 5. ABSTRACT FOR PRE-WORKSHOP SELF-EDUCATION Upper respiratory infections, commonly referred to the acronym URI or URTI, is the illness caused by an acute infection which involves the upper respiratory tract: nose, sinuses, pharynx or larynx. In the United States, this represents approximately one billion acute upper respiratory illnesses an Signs and symptoms Acute upper respiratory tract infections includes rhinosinusitis (common cold), sinusitis, pharyngitis/tonsillitis, laryngitis and sometimes bronchitis. Symptoms of URI's commonly include congestion, cough, running nose, sore throat, fever, facial pressure and sneezing. Onset of the symptoms usually begins after 1-3 days after exposure to a microbial pathogen, most commonly a virus. The duration of the symptoms is typically 7 to 10 days but may persist longer. It is important to mention that up to 15% of acute pharyngitis cases may be caused by bacteria, commonly Group A Strep ("Strep Throat"). Generally, patients with "Strep Throat" start with a sore throat as their first symptom and usually do not have runny nose or cough or sneezing. Pain and pressure of the ear caused by a middle ear infection (Otitis media) and the reddening of they eye caused by Viral Conjunctivitis are often associated with upper respiratory infections. Influenza (the flu) is a more systemic illness, which can also involve the upper respiratory tract, should be recognized as distinct from other causes of URI. Treatment Judicious use of antibiotics can decrease unnecessary adverse effects of antibiotics as well as out-of-pocket costs to the patient. But more important, decreased antibiotic usage will prevent development of drug resistant bacteria, which is now a growing problem in the world. International, as well as local US health agencies, have been strongly encouraging physicians to decrease the prescribing of antibiotics to treat common upper respiratory tract infections because antibiotic usage does not significantly reduce recovery time for these viral illnesses . Some have advocated a delayed antibiotic approach to treating URIswhich seeks to reduce the consumption of antibiotics while attempting to maintain patient satisfaction. Most studies show no difference in improvement of symptoms between those treated with antibiotics right away and those with delayed prescriptions. Most studies also show no difference in patient satisfaction, patient complications, symptoms between delayed and no antibiotics. It should be noted that a strategy of "no antibiotics" results in even less antibiotic use than a strategy of "delayed antibiotics". Until more effective treatments are available to treat the common respiratory viruses responsible for the majority of cases, treatment of URIs with rest, increased fluids, and symptomatic care with over-the-counter medications will remain the treatment of choice. However, in certain higher risk patients with underlying lung disease, such as chronic obstructive pulmonary disease (COPD), evidence does exist to support the treatment of URIs with antibiotics to shorten the course of illness and decrease treatment failure. The use of Vitamin C in the prevention and treatment of upper respiratory infections has been suggested since the initial isolation of vitamin C in the 1930s. Several studies have failed to demonstrate that vitamin C supplementation reduces the incidence of colds in the normal healthy population, indicating that routine large dose prophylaxis with Vitamin C is not beneficial in widespread community usage. Some evidence exists to indicate that it could be justified in persons exposed to brief periods of severe physical exercise and/or cold environments. The evidence does not support the use of Vitamin C at the onset of colds as effective therapy. TRACHEITIS Tracheitis is a bacterial infection of the trachea (wind pipe) capable of producing. Bacterial tracheitis is most often caused by Staphylococcus aureus and frequently follows a recent viral upper respiratory infection. It affects mostly young children, possibly because their small trachea is easily blocked by swelling. Children may still have a cough from their previous infection but this rapidly worsens. The child quickly develops stridor, a high pitched, crowing sound with breathing and increasing breathing difficulty. Fever is generally high and the child looks very ill. This condition may progress very rapidly. These children may sound as if they have croup, but the usual croup treatments do not improve the breathing difficulty.Tracheitis requires hospitalization and, usually, a breathing tube (endotracheal tube) in order to maintain an open airway. The infection is treated with an antistaphylococcal medications such as penicillin or a cephalosporin that covers Staphylococcus. If a different organism is at fault, the appropriate antibiotic is used. Pathophysiology Bacterial tracheitis is a diffuse inflammatory process of the larynx, trachea, and bronchi with adherent or semiadherentmucopurulent membranes within the trachea. The major site of disease is at the cricoid cartilage level, the narrowest part of the trachea. Acute airway obstruction may develop secondary to subglottic edema and sloughing of epithelial lining or accumulation of mucopurulent membrane within the trachea. Signs and symptoms are usually intermediate between those ofepiglottitis and croup. Bacterial tracheitis may be more common in the pediatric patient because of the size and shape of the subglottic airway. Thesubglottis is the narrowest portion of the pediatric airway, assuming a funnel-shaped internal dimension. In this smaller airway, relatively little edema can significantly reduce the diameter of the pediatric airway, increasing resistance to airflow and work of breathing. With appropriate airway support and antibiotics, most patients improve within 5 days. Although the pathogenesis of bacterial tracheitis is unclear, mucosal damage or impairment of local immune mechanisms due to a preceding viral infection, an injury to trachea from recent intubation, or trauma may predispose the airway to invasive infection with common pyogenic organisms. History Symptoms of bacterial tracheitis may be intermediately between those of epiglottitis and croup. Presentation is either acute orsubacute. In the classic presentation patients present acutely with fevers, toxic appearance, stridor, tachypnea, respiratory distress, and high WBC counts. Cough is frequent and not painful. In a study by Salamone et al, a significant subset of older children (mean age, 8 y) did not have severe clinical symptoms. The prodrome is usually an upper respiratory infection, followed by progression to higher fever, cough, inspiratory stridor, and a variable degree of respiratory distress. Patients may acutely decompensate with worsening respiratory distress due to airway obstruction from a purulent membrane that has loosened. Patients have been reported to present with symptoms and signs of bacterial tracheitis and multiorgan failure due to exotoxin-producing strains of Staphylococcus aureus or Streptococcus pyogenes in the trachea. A high index of suspicion for bacterial tracheitis is needed in children with viral croup–like symptoms who do not respond to standard croup treatment or clinically worsen. Causes S aureus: Community-associated methicillin-resistant S aureus (CA-MRSA) has recently emerged as an important agent in the United States; this could result in a greater frequency of MRSA strains that cause tracheitis. S pyogenes, Streptococcus pneumoniae, and other alpha hemolytic streptococcal species Moraxella catarrhalis: Recent reports suggest it is a leading cause of bacterial tracheitis and associated with increased intubation. Haemophilus influenzae type B (Hib): This cause is less common since the introduction of the Hib vaccine. Klebsiella species Pseudomonas species Anaerobes Peptostreptococcus species Bacteroides species Prevotella species Other: Mycoplasma pneumoniae Mycobacterium tuberculosis (endobronchial disease) Symptoms increasing deep or barking croup-like cough following a previous upper respiratory infection crowing sound when the child inhales (inspiratory stridor) high fever very sick-looking child (toxic) breathing difficulty, increasing in severity over time intercostal retractions (the muscles between the ribs pull in as the child attempts to breathe) Signs and tests nasopharyngeal culture (shows Staphylococcus aureus or other organisms) tracheal culture (shows Staphylococcus aureus or other organisms) blood gasses (show decreased oxygen saturation, decreased pO2) X-ray of the trachea (shows narrowing of the tracheal airway, but normal epiglottis) purulent (pus-filled) tracheal secretions may be obtained while placing the breathing tube in the patient Treatment Treatment of bacterial tracheitis consists of the following: Airway Maintenance of an adequate airway is of primary importance. Avoid agitating the child. If the patient's respiratory status deteriorates, it is usually because of movement of the membrane, and bag-valve-mask ventilation should be effective. If intubation is required, use an endotracheal tube 0.5-1 size smaller than expected in order to minimize trauma in the inflamed subglottic area. Frequent suctioning and high air humidity is necessary to maintain endotrachealtube patency; therefore, use the most appropriate-sized tube (without causing trauma). Most patients (57-100%) require eventual intubation. Intravenous access and medication Once the airway is stabilized, obtain intravenous access for initiation of antibiotics. Antibiotic regimens have traditionally included a third-generation cephalosporin (eg, cefotaxime, ceftriaxone) and apenicillinaseresistant penicillin (eg, oxacillin, nafcillin). Recently, clindamycin (40 mg/kg/d intravenously [IV], divided every 8 h) is used instead of penicillinase-resistant penicillin against community acquired– methicillin-resistant S aureus (CA-MRSA) in places where resistance rates of CA-MRSA to clindamycin is low.6 Vancomycin (45 mg/kg/d IV, divided every 8 h), with or without clindamycin, should be started in patients who appear toxic or have multiorgan involvement or if MRSA is prevalent in the community. The child often needs to have an airway or breathing tube placed (endotracheal tube). Antibiotics are given through a vein, usually a type of penicillin or one of the cephalosporins. Oxygen is usually given, and the blood gases are monitored to be sure that the child is breathing adequately. Surgical Care Tracheostomy Tracheostomy is rarely necessary unless injury or trauma to the airway has caused scarring and documented narrowing of the airway. Tracheostomy is necessary if the patient has failed extubations despite appropriate medical management or if intubation is prolonged. Pulmonary toilet is potentially better with tracheostomy. Consultations Otorhinolaryngology - For endoscopic procedures and acute airway management Pediatric intensivist - Necessary because of potential for acute decompensation Medication Antibiotic agents Empiric antimicrobial therapy in bacterial tracheitis must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Expectations (prognosis) Full recovery is expected if the patient can be brought to a medical facility in time. fairway obstruction with cardiorespiratory arrest and possibly death — the breathing stops, then the heartbeat stops toxic shock syndrome (only if the organism is Staphylococcus) Rhinitis Rhinitis (pron.: /raɪˈnaɪtɪs/) is a medical term for irritation and inflammation of the mucous membrane inside the nose. Common symptoms of rhinitis are a stuffy nose, runny nose, and post-nasal drip. The most common kind of rhinitis is allergic rhinitis, which is usually triggered by airborne allergens such as pollen and dander. Allergic rhinitis may cause additional symptoms, such as sneezing and nasal itching, coughing, headache, fatigue, malaise, and cognitive impairment. The allergens may also affect the eyes, causing watery, reddened or itchy eyes and puffiness around the eyes. Rhinitis is very common. Allergic rhinitis is more common in some countries than others; in the United States, about 10%-30% of adults are affected annually. In rhinitis, the inflammation of the mucous membrane is caused by viruses, bacteria, irritants or allergens. The inflammation results in the generation of large amounts of mucus, commonly producing a runny nose, as well as a stuffy nose and post-nasal drip. In the case of allergic rhinitis, the inflammation is caused by the degranulation of mast cells in the nose. When mast cellsdegranulate, they release histamine and other chemicals, starting an inflammatory process that can cause symptoms outside the nose, such as fatigue and malaise. Types Rhinitis is categorized into three types: (i) infective rhinitis includes acute and chronic bacterial infections; (ii) nonallergic(vasomotor) rhinitis includes autonomic, hormonal, drug-induced, atrophic, and gustatory rhinitis, as well as rhinitismedicamentosa; (iii) allergic rhinitis, triggered by pollen, mold, animal dander, dust and other similar inhaled allergens. Infectious Rhinitis is commonly caused by a viral or bacterial infection, including the common cold, which is caused by Rhinoviruses andCoronaviruses, or bacterial sinusitis. Symptoms of the common cold include rhinorrhea, sore throat (pharyngitis), cough, congestion, and slight headache. Vasomotor rhinitis Non-allergic rhinitis refers to runny nose that is not due to allergy. Non-allergic rhinitis can be classified as either non-inflammatory or inflammatory rhinitis. One very common type of non-inflammatory, non-allergic rhinitis that is sometimes confused with allergy is called vasomotor rhinitis, in which certain nonspecific stimuli, including changes in environment (temperature, humidity, barometric pressure, or weather); airborne irritants (odors, fumes); dietary factors (spicy food, alcohol); sexual arousal; and emotional factors. There is still much to be learned about this entity, but it is thought that these non-allergic triggers cause dilation of the blood vessels in the lining of the nose, which results in swelling, and drainage. Vasomotor rhinitis can coexist with allergic rhinitis, and this is called "mixed rhinitis." (Middleton's Allergy Principles and Practice, seventh edition.) The pathology of vasomotor rhinitis appears to involve neurogenic inflammation and is as yet not very well understood. Vasomotor rhinitis appears to be significantly more common in women than men, leading some researchers to believe that hormones play a role. In general, age of onset occurs after 20 years of age, in contrast to allergic rhinitis which can be developed at any age. Individuals suffering from vasomotor rhinitis typically experience symptoms year-round, though symptoms may be exacerbated in the spring and autumn when rapid weather changes are more common. An estimated 17 million United States citizens have vasomotor rhinitis. The antihistamines azelastine and olopatadine, applied as nasal sprays, may both be effective for vasomotor rhinitis. Fluticasone propionate or budesonide (both are steroids) in nostril spray form may also be used for symptomatic treatment. Allergic Pollen grains from a variety of common plants can cause hay fever Allergic rhinitis or hay fever may follow when an allergen such as pollen or dust is inhaled by an individual with a sensitized immune system, triggering antibody production. These antibodies mostly bind to mast cells, which contain histamine. When the mast cells are stimulated by pollen and dust, histamine (and other chemicals) are released. This causes itching, swelling, and mucus production. Symptoms vary in severity between individuals. Very sensitive individuals can experience hives or other rashes. Particulate matter in polluted air and chemicals such as chlorine and detergents, which can normally be tolerated, can greatly aggravate the condition. Characteristic physical findings in individuals who have allergic rhinitis include conjunctival swelling and erythema, eyelid swelling, lower eyelid venous stasis, lateral crease on the nose, swollen nasal turbinates, and middle ear effusion. Even if a person has negative skin-prick, intradermal and blood tests for allergies, they may still have allergic rhinitis, from a local allergy in the nose. This is called local allergic rhinitis. Many people who were previously diagnosed with nonallergicrhinitis may actually have local allergic rhinitis. detergents, which can normally be tolerated, can greatly aggravate allergic rhinitis. The physician John Bostock first described hay fever in 1819 as a disease. The characteristic symptoms of allergic rhinitis are: rhinorrhea (excess nasal secretion), itching, and nasal congestion and obstruction. Characteristic physical findings include conjunctival swelling and erythema, eyelid swelling, lower eyelid venous stasis, swollen nasal turbinates, and middle ear effusion. Other physical signs include folds in the skin below the lower eyelid known as Dennie–Morgan folds, and rings under the eyes, known in patients with allergic rhinitis as "allergic shiners". There can also be behavioural signs; in order to relieve the irritation or flow of mucus, patients may wipe or rub their nose with the palm of their hand in an upward motion: an action known as the "nasal salute" or the "allergic salute". Management The goal of rhinitis treatment is to prevent or reduce the symptoms caused by the inflammation of affected tissues. Measures which are effective include avoiding the allergen. Intranasal corticosteroids are the preferred treatment if medications are required with other options used only if these are not effective. Mite proof covers, air filters, and withholding certain foods in childhood do not have evidence supporting their effectiveness. Steroids Intranasal corticosteroids are used to control symptoms associated with sneezing, rhinorrhea, itching and nasal congestion. It is an excellent choice for perennial rhinitis. Steroid nasal sprays are effective and safe, and may be effective without oral antihistamines. They take several days to act and so need be taken continually for several weeks as their therapeutic effect builds up with time. Systemic steroids such as prednisone are effective at reducing nasal inflammation, but their use is limited by their short duration of effect and the side effects of prolonged steroid therapy. Other Other measures that may be used second line include: antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies such as nasal irrigation. Antihistamine drugs can have undesirable side-effects, most notably drowsiness. First generation antihistamine drugs such asdiphenhydramine cause drowsiness, but not second- and third-generation antihistamines such as cetirizine and loratadine. Antihistamine drugs can be taken orally to control symptoms such as sneezing, rhinorrhea, itching and conjunctivitis. It is best to take the medication before exposure, especially for seasonal allergic rhinitis. Ophthalmic antihistamines (such as ketotifen) are used for conjunctivitis; intranasal forms are used for sneezing, rhinorrhea and nasal pruritus. Pseudoephedrine is also indicated for vasomotor rhinitis. It is only used when nasal congestion is present and can be used with antihistamines. In the United States, oral decongestants containing pseudoephedrine must be purchased behind the pharmacy counter by law to combat the making of methamphetamine. Topical decongestants: may also be helpful in reducing symptoms such as nasal congestion, but should not be used for long periods as stopping them after protracted use can lead to a rebound nasal congestion (Rhinitis medicamentosa). For nocturnal symptoms, intranasal corticosteroids can be combined with nightly oxymetazoline, an adrenergic alpha-agonist, without risk of rhinitis medicamentosa. Desensitization Common cold The common cold (also known as nasopharyngitis, rhinopharyngitis, acute coryza, or a cold) is a viral infectious disease of the upper respiratory tract which affects primarily the nose. Symptoms include coughing, sore throat, runny nose, and fever which usually resolve in seven to ten days, with some symptoms lasting up to three weeks. Well over 200 viruses are implicated in the cause of the common cold; the rhinoviruses are the most common. Upper respiratory tract infections are loosely divided by the areas they affect, with the common cold primarily affecting the nose, the throat (pharyngitis), and the sinuses (sinusitis). Symptoms are mostly due to the body's immune response to the infection rather than to tissue destruction by the viruses themselves. The primary method of prevention is by hand washing with some evidence to support the effectiveness of wearing face masks. No cure for the common cold exists, but the symptoms can be treated. It is the most frequent infectious disease in humans with the average adult contracting two to three colds a year and the average child contracting between six and twelve. Theseinfections have been with humanity since antiquity. Signs and symptoms The typical symptoms of a cold include cough, runny nose, nasal congestion and a sore throat, sometimes accompanied by muscle ache, fatigue, headache, and loss of appetite. A sore throat is present in about 40% of the cases and a cough in about 50%, while muscle ache occurs in about half. In adults, a fever is generally not present but it is common in infants and young children. The cough is usually mild compared to that accompanying influenza. While a cough and a fever indicate a higher likelihood of influenza in adults, a great deal of similarity exists between these two conditions. A number of the viruses that cause the common cold may also result in asymptomatic infections. The color of the sputum or nasal secretion may vary from clear to yellow to green and does not predict the class of agent causing the infection. Progression A cold usually begins with fatigue, a feeling of being chilled, sneezing and a headache, followed in a couple of days by a runny nose and cough. Symptoms may begin within 16 hours of exposure and typically peak two to four days after onset. They usually resolve in seven to ten days but some can last for up to three weeks. In children, the cough lasts for more than ten days in 35–40% of the cases and continues for more than 25 days in 10%. Cause:Viruses The common cold is a viral infection of the upper respiratory tract. The most commonly implicated virus is a rhinovirus (30–80%), a type of picornavirus with 99 known serotypes. Others include: coronavirus (10–15%), human parainfluenza viruses, human respiratory syncytial virus, adenoviruses, enteroviruses, and metapneumovirus. Frequently more than one virus is present. In total over 200 different viral types are associated with colds. Transmission The common cold virus is typically transmitted via airborne droplets (aerosols), direct contact with infected nasal secretions, orfomites (contaminated objects). Which of these routes is of primary importance has not been determined. The viruses may survive for prolonged periods in the environment and can be picked up by people's hands and subsequently carried to their eyes or nose where infection occurs. Transmission is common in daycare and at school due to the close proximity of many children with little immunity and frequently poor hygiene. These infections are then brought home to other members of the family. There is no evidence that recirculated air during commercial flight is a method of transmission. However, people sitting in close proximity appear at greater risk. Rhinovirus-caused colds are most infectious during the first three days of symptoms; they are much less infectious afterwards. Weather The traditional folk theory is that a cold can be "caught" by prolonged exposure to cold weather such as rain or winter conditions, which is how the disease got its name. The role of body cooling as a risk factor for the common cold is controversial. Some of the viruses that cause the common colds are seasonal, occurring more frequently during cold or wet weather. Some believe this to be due primarily to increased time spent indoors in close proximity; specifically children returning to school. However, it may also be related to changes in the respiratory system that result in greater susceptibility. Low humidity increases viral transmission rates potentially due to dry air allowing small viral droplets to disperse farther and stay in the air longer. Other Herd immunity, generated from previous exposure to cold viruses, plays an important role in limiting viral spread, as seen with younger populations that have greater rates of respiratory infections. Poor immune function is also a risk factor for disease. Insufficient sleep and malnutrition have been associated with a greater risk of developing infection following rhinovirus exposure; this is believed to be due to their effects on immune function. Pathophysiology The common cold is a disease of the upper respiratory tract. The symptoms of the common cold are believed to be primarily related to the immune response to the virus. The mechanism of this immune response is virus specific. For example, the rhinovirus is typically acquired by direct contact; it binds to human ICAM-1 receptors through unknown mechanisms to trigger the release of inflammatory mediators. These inflammatory mediators then produce the symptoms. It does not generally cause damage to the nasal epithelium. The respiratory syncytialvirus (RSV) on the other hand is contracted by both direct contact and air born droplets. It then replicates in the nose and throat before frequently spreading to the lower respiratory tract. RSV does cause epithelium damage. Human parainfluenzavirus typically results in inflammation of the nose, throat, and bronchi. In young children when it affects the trachea it may produce the symptoms of croup due to the small size of their airway. Diagnosis The distinction between different viral upper respiratory tract infections is loosely based on the location of symptoms with the common cold affecting primarily the nose, pharyngitis the throat, and bronchitis the lungs. There however can be significant overlap and multiple areas can be affected. The common cold is frequently defined as nasal inflammation with varying amount of throat inflammation. Self-diagnosis is frequent. Isolation of the actual viral agent involved is rarely performed, and it is generally not possible to identify the virus type through symptoms. Prevention Physical measures to prevent the spread of cold viruses have been deemed the only potentially effective measures for prevention. These measures include primarily hand washing and face masks; in the health care environment, gowns and disposable gloves are also used. Efforts such as quarantine are not possible as the disease is so widespread and symptoms are non-specific. Vaccination has proved difficult as there are so many viruses involved and they change rapidly. Creation of a broadly effective vaccine is thus highly improbable. Regular hand washing appears to be effective at reducing the transmission of cold viruses especially among children. Whether the addition of antivirals or antibacterials to normal hand washing provides greater benefit is unknown. Wearing face masks when around people who are infected may be beneficial; however, there is insufficient evidence for maintaining a greater social distance. Zinc supplementation may be effective at decreasing the rate of colds.[36] Routine vitamin C supplementation does not reduce the risk or severity of the common cold, though it may reduce its duration. Management There are currently no medications or herbal remedies which have been conclusively demonstrated to shorten the duration of infection. Treatment thus comprises symptomatic relief. Getting plenty of rest, drinking fluids to maintain hydration, and gargling with warm salt water, are reasonable conservative measures. Much of the benefit from treatment is however attributed to the placebo effect. Symptomatic Treatments that help alleviate symptoms include simple analgesics and antipyretics such as ibuprofen and acetaminophen/paracetamol. Evidence does not show that cough medicines are any more effective than simple analgesics and they are not recommended for use in children due to a lack of evidence supporting effectiveness and the potential for harm. In 2009, Canada restricted the use of overthe-counter cough and cold medication in children six years and under due to concerns regarding risks and unproven benefits. In adults there is insufficient evidence to support the use of cough medications in adults. The misuse of dextromethorphan (an over-the-counter cough medicine) has led to its ban in a number of countries. In adults the symptoms of a runny nose can be reduced by first-generation antihistamines; however, they are associated with adverse effects such as drowsiness. Other decongestants such as pseudoephedrine are also effective in this population.Ipratropium nasal spray may reduce the symptoms of a runny nose but there is little effect on stuffiness. Second-generation antihistamines however do not appear to be effective. Due to lack of studies, it is not known whether increased fluid intake improves symptoms or shortens respiratory illness and a similar lack of data exists for the use of heated humidified air. One study has found chest vapor rub to be effective at providing some symptomatic relief of nocturnal cough, congestion, and sleep difficulty. Antibiotics and antivirals Antibiotics have no effect against viral infections and thus have no effect against the viruses that cause the common cold. Due to their side effects they cause overall harm; however, they are still frequently prescribed. Some of the reasons that antibiotics are so commonly prescribed include: people's expectations for them, physicians' desire to do something, and the difficulty in excluding complications that may be amenable to antibiotics. There are no effective antiviral drugs for the common cold even though some preliminary research has shown benefit. Alternative treatments While there are many alternative treatments used for the common cold, there is insufficient scientific evidence to support the use of most. As of 2010 there is insufficient evidence to recommend for or against either honey or nasal irrigation. Studies suggested that zinc, if taken within 24 hours of the onset of symptoms, reduces the duration and severity of the common cold in healthy people. Due to wide differences between the studies, further research may be needed to determine how and when zinc may be effective. Vitamin C's effect on the common cold while extensively researched is disappointing, except in limited circumstances, specifically, individuals exercising vigorously in cold environments. Evidence about the usefulness of echinaceais inconsistent. Different types of echinacea supplements may vary in their effectiveness. It is unknown if garlic is effective.[64] A single trial of vitamin D did not find benefit. Prognosis The common cold is generally mild and self-limiting with most symptoms generally improving in a week. Severe complications, if they occur, are usually in the very old, the very young or those who are immunosuppressed. Secondary bacterial infections may occur resulting in sinusitis, pharyngitis, or an ear infection. It is estimated that sinusitis occurs in 8% and an ear infection in 30% of cases. Epidemiology The common cold is the most common human disease and all peoples globally are affected. Adults typically have two to five infections annually and children may have six to ten colds a year (and up to twelve colds a year for school children). Rates of symptomatic infections increase in the elderly due to a worsening immune system. Research A number of antivirals have been tested for effectiveness in the common cold; however as of 2009 none have been both found effective and licensed for use. Researchersfrom University of Maryland, CollegePark and University of Wisconsi n–Madison have mapped the genome for all known virus strains that cause the common cold ACUTE BRONCHITIS CLINICAL MANIFESTATIONS. Acute bronchitis is commonly preceded by a viral upper respiratory tract infection. It is more common in the winter when respiratory viral syndromes predominate. The tracheobronchial epithelium is invaded by the infectious agent, leading to activation of inflammatory cells and release of cytokines. Constitutional symptoms, such as fever and malaise, follow. The tracheobronchial epithelium may become significantly damaged or hypersensitized, leading to a protracted cough lasting 1–3 wk. The child 1st presents with nonspecific upper respiratory infectious symptoms, such as rhinitis. Three to 4 days later, a frequent, dry, hacking cough develops, which may or may not be productive. After several days, the sputum may become purulent, indicating leukocyte migration but not necessarily bacterial infection. Many children swallow their sputum, and this may produce emesis. Chest pain may be a prominent complaint in older children, exacerbated by coughing. The mucus gradually thins, usually within 5–10 days, and then the cough gradually abates. The entire episode usually lasts about 2 wk and seldom longer than 3 wk. Findings on physical examination vary with age of the patient and stage of the disease. Early findings are absent or are low-grade fever and upper respiratory signs such as nasopharyngitis, conjunctivitis, and rhinitis. Auscultation of the chest may be unremarkable at this early phase. As the syndrome progresses and cough worsens, breath sounds become coarse, with coarse and fine crackles and scattered high-pitched wheezing. Chest radiographs are normal or may have increased bronchial markings. The principal objective of the clinician is to exclude pneumonia, which is more likely caused by bacterial agents requiring antibiotic therapy. In adults, absence of abnormality of vital signs (tachycardia, tachypnea, fever) and a normal physical examination of the chest reduce the likelihood of pneumonia. DIFFERENTIAL DIAGNOSIS. Persistent or recurrent symptoms should lead the clinician to consider entities other than acute bronchitis. Many entities manifest with cough as a prominent symptom ( Table 388-3 ). TABLE 388-3 -- Disorders with Cough as a Prominent Finding CATEGORY DIAGNOSES Inflammatory Asthma Chronic pulmonary processes Bronchopulmonary dysplasia/chronic lung disease Postinfectious bronchiectasis Cystic fibrosis Tracheo- or bronchomalacia Ciliary abnormalities Other chronic disease/congenital disorders Laryngeal cleft Swallowing disorders Gastroesophageal reflux Airway compression (such as a vascular ring or hemangioma) Congenital heart disease Infectious/immune disorders Immunodeficiency Tuberculosis Allergy Sinusitis Tonsillitis or adenoiditis Chlamydia, Ureaplasma (infants) Bordetella pertussis Mycoplasma pneumoniae Acquired Foreign body aspiration, tracheal or esophageal TREATMENT.There is no specific therapy for acute bronchitis. The disease is selflimited, and antibiotics, although frequently prescribed, do not hasten improvement. Frequent shifts in position may facilitate pulmonary drainage in infants. Older children are sometimes more comfortable with humidity, but this does not shorten the disease course. Cough suppressants may produce symptomatic relief but may also increase the risk of suppuration and inspissated secretions and, therefore, should be used judiciously. Antihistamines dry secretions and are not helpful; expectorants are likewise not indicated. ACUTE BRONCHIOLITIS AND INFLAMMATION OF THE AIRWAY. Infection can cause obstruction to flow by internal narrowing of the airways. Acute bronchiolitis is predominantly a viral disease. Respiratory syncytial virus (RSV) is responsible for >50% of cases (see Chapter 257 ). Other agents include parainfluenza (see Chapter 256 ), adenovirus, Mycoplasma, and, occasionally, other viruses. Human metapneumovirus (see Chapter 258 ) is an important primary cause of viral respiratory infection or it can occur as a co-infection with RSV. There is no evidence of a bacterial cause for bronchiolitis, although bacterial pneumonia is sometimes confused clinically with bronchiolitis and bronchiolitis is rarely followed by bacterial superinfection. Approximately 50,000–80,000 of hospitalizations annually among children <1 yr old are attributable to RSV infection, with 200–500 deaths per yr in the United States. Increasing rates of hospitalization may reflect increased attendance of infants in daycare centers, changes in criteria for hospital admission, and/or improved survival of premature infants and others at risk for severe RSVassociated disease. Bronchiolitis is more common in males, in those who have not been breast-fed, and in those who live in crowded conditions. Older family members are a common source of infection; they may only experience minor respiratory symptoms. The clinical manifestations of lower respiratory tract illness (LRTI) seen in young infants may be minimal in older patients, in whom bronchiolar edema is better tolerated. Not all infected infants develop LRTI. Host anatomic and immunologic factors seem to play a significant role in the severity of the clinical syndrome. Infants with pre-existent smaller airways and diminished lung function have a more severe course. In addition, RSV infection incites a complex immune response. Eosinophils degranulate and release eosinophil cationic protein, which is cytotoxic to airway epithelium. Immunoglobulin E (IgE) antibody release may also be related to wheezing. Other mediators invoked in the pathogenesis of airway inflammation include chemokines such as interleukin 8 (IL-8), macrophage inflammatory protein (MIP) 1α, and RANTES (regulated on activation, normal Tcell expressed and secreted). RSV-infected infants who wheeze express higher levels of interferon-γ in the airway as well as leukotrienes. RSV co-infection with metapneumovirus can be more severe than monoinfection. Acute bronchiolitis is characterized by bronchiolar obstruction with edema, mucus, and cellular debris. Even minor bronchiolar wall thickening significantly affects airflow because resistance is inversely proportional to the 4th power of the radius of the bron chiolar passage. Resistance in the small air passages is increased during both inspiration and exhalation, but because the radius of an airway is smaller during expiration, the resultant respiratory obstruction leads to early air trapping and overinflation. If obstruction becomes complete, there will be resorption of trapped distal air, and the child will develop atelectasis. Hypoxemia is a consequence of ventilation-perfusion mismatch early in the course. With severe obstructive disease and tiring of respiratory effort, hypercapnia may develop. Chronic infectious causes of wheezing should be considered in those infants who seem to fall out of the range of a normal clinical course. Cystic fibrosis is one such entity; suspicion increases in a patient with persistent respiratory symptoms, digital clubbing, malabsorption, failure to thrive, electrolyte abnormalities, or a resistance to bronchodilator treatment (see Chapter 400 ). Allergy and asthma are important causes of wheezing and probably generate the most questions by the parents of a wheezing infant. Asthma is characterized by airway inflammation, bronchial hyperreactivity, and reversibility of obstruction (see Chapter 143 ). Three identified patterns of infant wheezing are: the transient early wheezer, 19.9% of the general population, had wheezing at least once with a lower respiratory infection before the age of 3 yr but never wheezed again; the persistent wheezer, 13.7% of the general population, had wheezing episodes before 3 yr and was still wheezing at 6 yr of age; and the late onset wheezer, 15% of the general population, had no wheezing by 3 yr but was wheezing by 6 yr. The other ½ of the children had never wheezed by 6 yr. Of all the infants who wheezed before 3 yr old, almost 60% stopped wheezing by 6 yr. Risk factors for persistent wheezing included maternal asthma, maternal smoking, persistent rhinitis (apart from acute upper respiratory tract infections), and eczema at <1 yr of age. OTHER CAUSES. Congenital malformations of the respiratory tract cause wheezing in early infancy. These findings can be diffuse or focal and can be from an external compression or an intrinsic abnormality. External vascular compression includes a vascular ring, in which the trachea and esophagus are surrounded completely by vascular structures, or a vascular sling, in which the trachea and esophagus are not completely encircled (see Chapter 432 ). Cardiovascular causes of wheezing include dilated chambers of the heart including massive cardiomegaly, left atrial enlargement, and dilated pulmonary arteries. Pulmonary edema caused by heart failure can also cause wheezing by lymphatic and bronchial vessel engorgement that leads to obstruction and edema of the bronchioles and further obstruction (see Chapter 442 ). Foreign body aspiration (see Chapter 384 ) can cause acute or chronic wheezing. It is estimated that 78% of those who die from foreign body aspiration are between 2 mo and 4 yr old. Even in young infants, a foreign body can be ingested if given to the infant by another person such as an older sibling. Infants who have atypical histories or misleading clinical and radiologic findings may be misdiagnosed with asthma or another obstructive disorder as inflammation and granulation develop around the foreign body. Esophageal foreign body can transmit pressure to the membranous trachea, causing compromise of the airway lumen. Gastroesophageal reflux (see Chapter 320.1 ) can cause wheezing with or without direct aspiration into the tracheobronchial tree. Without aspiration, the reflux is thought to trigger a vagal or neural reflex, causing increased airway resistance and airway reactivity. Aspiration from gastroesophageal reflux or from the direct aspiration from oral liquids can also cause wheezing.Trauma and tumors are much more rare causes of wheezing in infants. Trauma of any type to the tracheobronchial tree can cause an obstruction to airflow. Accidental or nonaccidental aspirations, burns, or scalds of the tracheobronchial tree can cause inflammation of the airways and subsequent wheezing. Any space-occupying lesion either in the lung itself or extrinsic to the lung can cause tracheobronchial compression and obstruction to airflow. CLINICAL MANIFESTATIONS HISTORY AND PHYSICAL EXAMINATION. Initial history of a wheezing infant should include accounts of the recent event including onset, duration, and associated factors ( Table 388-2 ). Birth history includes weeks of gestation, neonatal intensive care unit admission, history of intubation or oxygen requirement, maternal complications including infection, herpes simplex virus (HSV) status, HIV status, and prenatal smoke exposure. Past medical history includes any co-morbid conditions including syndromes or associations. Family history of cystic fibrosis, immunodeficiencies, asthma in a 1st-degree relative, or any other recurrent respiratory conditions in children should be obtained. Social history should include an environmental history including any smokers at home, inside or out, daycare exposure, number of siblings, occupation of inhabitants of the home, pets, tuberculosis exposure, and concerns regarding home environment (i.e. dust mites, construction dust, heating and cooling techniques, mold, cockroaches). TABLE 388-2 -- Pertinent Medical History in the Wheezing Infant Did the onset of symptoms begin at birth or thereafter? Is the infant a noisy breather and when is it most prominent? Is there a history of cough apart from wheezing? Was there an earlier lower respiratory tract infection? Have there been any emergency department visits, hospitalizations, or intensive care unit admissions for respiratory distress? Is there a history of eczema? Does the infant cough after crying or cough at night? How is the infant growing and developing? Is there associated failure to thrive? Is there failure to thrive without feeding difficulties? Is there a history of electrolyte abnormalities? Are there signs of intestinal malabsorption including frequent, greasy, or oily stools? Is there a maternal history of genital herpes simplex virus (HSV) infection? What was the gestational age at delivery? Was the patient intubated as a neonate? Does the infant bottle-feed in the bed or the crib, especially in a propped position? Are there any feeding difficulties including choking, gagging, arching, or vomiting with feeds? Any new food exposure? Is there a toddler in the home or lapse in supervision in which foreign body aspiration could have occurred? Change in caregivers or chance of nonaccidental trauma? On physical examination, evaluation of the patient's vital signs with special attention to the respiratory rate and the pulse oximetry reading for oxygen saturation is an important initial step. There should also be a thorough review of the patient's growth chart for signs of failure to thrive. Wheezing produces an expiratory whistling sound that can be polyphonic or monophonic in nature. Prolonged expiratory time may be present. Biphasic wheezing can occur if there is a central, large airway obstruction. The lack of audible wheezing is not reassuring if the infant shows other signs of respiratory distress because complete obstruction to airflow can eliminate the turbulence, which causes the sound to resonate. Aeration should be noted and a trial of a bronchodilator may be warranted to evaluate for any change in wheezing after treatment. Listening to breath sounds over the neck will help differentiate upper airway from lower airway sounds. The absence or presence of stridor should be noted and appreciated on inspiration. Signs of respiratory distress include tachypnea, increased respiratory effort, nasal flaring, tracheal tugging, subcostal and intercostal retractions, and excess use of accessory muscles. In the upper airway, signs of atopy, including boggy turbinates and posterior oropharynx cobblestoning, can be evaluated in older infants. It is also useful to evaluate the skin of the patient for eczema and any significant hemangiomas; midline lesions may be associated with an intrathoracic lesion. Digital clubbing should be noted (see Chapter 371 ). Acute bronchiolitis is usually preceded by exposure to an older contact with a minor respiratory syndrome within the previous wk. The infant 1st develops a mild upper respiratory tract infection with sneezing and clear rhinorrhea. This may be accompanied by diminished appetite and fever of 38.5–39°C (101–102°F), although the temperature may range from subnormal to markedly elevated. Gradually, respiratory distress ensues, with paroxysmal wheezy cough, dyspnea, and irritability. The infant is often tachypneic, which may interfere with feeding. The child does not usually have other systemic complaints, such as diarrhea or vomiting. Apnea may be more prominent than wheezing early in the course of the disease, particularly with very young infants (<2 mo old) or former premature infants. The physical examination is characterized most prominently by wheezing. The degree of tachypnea does not always correlate with the degree of hypoxemia or hypercarbia, so the use of pulse oximetry and noninvasive carbon dioxide determination is essential. Work of breathing may be markedly increased, with nasal flaring and retractions. Auscultation may reveal fine crackles or overt wheezes, with prolongation of the expiratory phase of breathing. Barely audible breath sounds suggest very severe disease with nearly complete bronchiolar obstruction. Hyperinflation of the lungs may permit palpation of the liver and spleen. DIAGNOSTIC EVALUATION. Initial evaluation is dependent on likely etiology; a baseline chest radiograph, including posteroanterior and lateral films, is warranted in many cases and for any infant in acute respiratory distress. Focal infiltrates are most often found in wheezing infants who have a pulse oximetry reading <93%, grunting, decreased breath sounds, prolonged inspiratory to expiratory ratio, and crackles. The chest radiograph may also be useful for evaluation of hyperinflation (common in bronchiolitis and viral pneumonia), signs of chronic disease such as bronchiectasis, or a space-occupying lesion causing airway compression. A trial of bronchodilator may be diagnostic as well as therapeutic because these medications can reverse conditions such as bronchiolitis (occasionally) and asthma but will not affect a fixed obstruction. Bronchodilators may potentially worsen a case of wheezing caused by tracheal or bronchial malacia. A sweat test to evaluate for cystic fibrosis and evaluation of baseline immune status are reasonable in infants with recurrent wheezing or complicated courses. Further evaluation such as upper gastrointestinal (GI) contrast x-rays, chest CT, bronchoscopy, infant pulmonary function testing, video swallow study, and pH probe can be considered second-tier diagnostic procedures in complicated patients. In acute bronchiolitis, chest radiography reveals hyperinflated lungs with patchy atelectasis. The white blood cell and differential counts are usually normal. Viral testing (usually rapid immunofluorescence, polymerase chain reaction, or viral culture) is helpful if the diagnosis is uncertain or for epidemiologic purposes. The diagnosis is clinical, particularly in a previously healthy infant presenting with a first-time wheezing episode during a community outbreak. Because concurrent bacterial infection (sepsis, pneumonia, meningitis) is highly unlikely, confirmation of viral bronchiolitis may obviate the need for a sepsis evaluation in a febrile infant and assist with respiratory precautions and isolation if the patient requires hospitalization. TREATMENT Treatment of an infant with wheezing depends on the underlying etiology. Response to bronchodilators is unpredictable, regardless of cause, but suggests a component of bronchial hyperreactivity. It is appropriate to administer albuterol aerosol and objectively observe the response. For infants <3 yr of age, it is acceptable to continue to administer inhaled medications through an MDI with mask and spacer if a therapeutic benefit is demonstrated. Therapy should be continued in all patients with asthma exacerbations from a viral illness. The use of ipratropium bromide in this population is controversial, but it appears to be somewhat effective as an adjunct therapy. It is also useful in infants with significant tracheal and bronchial malacia who may be made worse by β-2 agonists such as albuterol because of the subsequent decrease in smooth muscle tone. A trial of inhaled steroids may be warranted in a patient who has responded to multiple courses of oral steroids, has moderate to severe wheezing, or a significant history of atopy including food allergy or eczema. Inhaled steroids are appropriate for maintenance therapy in patients with known reactive airways but are controversial when used for episodic or acute illnesses. Oral steroids are generally reserved for atopic wheezing infants thought to have asthma that is refractory to other medications. Their use in first-time wheezing infants or those infants that do not warrant hospitalization is controversial. Infants with acute bronchiolitis who are experiencing respiratory distress should be hospitalized; the mainstay of treatment is supportive. If hypoxemic, the child should receive cool humidified oxygen. Sedatives are to be avoided because they may depress respiratory drive. The infant is sometimes more comfortable if sitting with head and chest elevated at a 30-degree angle with neck extended. The risk of aspiration of oral feedings may be high in infants with bronchiolitis, owing to tachypnea and the increased work of breathing. The infant may be fed through a nasogastric tube. If there is any risk for further respiratory decompensation potentially necessitating tracheal intubation, however, the infant should not be fed orally but be maintained with parenteral fluids. Frequent suctioning of nasal and oral secretions often provides relief of distress or cyanosis. Oxygen is indicated in all infants with hypoxia. A number of agents have been proposed as adjunctive therapies for bronchiolitis. Bronchodilators produce modest short-term improvement in clinical features, but the statistical improvement in clinical scoring systems seen with them is not always clinically significant. Several studies have included both infants with 1sttime wheezing and those with recurrent wheezing, complicating interpretation of the data. Nebulized epinephrine may be more effective than β-agonists. A trial dose of inhaled bronchodilator may be reasonable, with further therapy predicated on response in the individual patient. Corticosteroids, whether parenteral, oral, or inhaled, have been used for bronchiolitis despite conflicting and often negative studies. Differences of diagnostic criteria, measures of effect, timing and route of administration, and severity of illness complicate these studies. Corticosteroids are not recommended in previously healthy infants with RSV. Ribavirin, an antiviral agent administered by aerosol, has been used for infants with congenital heart disease or chronic lung disease. There is no convincing evidence of a positive impact on clinically important outcomes such as mortality and duration of hospitalization. Antibiotics have no value unless there is secondary bacterial pneumonia. Likewise, there is no support for RSV immunoglobulin administration during acute episodes of RSV bronchiolitis. PROGNOSIS Infants with acute bronchiolitis are at highest risk for further respiratory compromise in the 1st 48–72 hr after onset of cough and dyspnea; the child may be desperately ill with air hunger, apnea, and respiratory acidosis. The case fatality rate is <1%, with death attributable to apnea, uncompensated respiratory acidosis, or severe dehydration. After this critical period, symptoms may persist. The median duration of symptoms in ambulatory patients is ≈12 days. Infants with conditions such as congenital heart disease, bronchopulmonary dysplasia, and immunodeficiency often have more severe disease, with higher morbidity and mortality. There is a higher incidence of wheezing and asthma in children with a history of bronchiolitis unexplained by family history or other atopic syndromes. It is unclear whether bronchiolitis incites an immune response that manifests as asthma later or whether those infants have an inherent predilection for asthma that is merely unmasked by their episode of RSV. Approximately 60% of infants who wheeze will stop wheezing. PREVENTION Reduction in the severity and incidence of acute bronchiolitis due to RSV is possible through the administration of pooled hyperimmune RSV intravenous immunoglobulin (RSV-IVIG, RespiGam) and palivizumab (Synagis), an intramuscular monoclonal antibody to the RSV F protein, before and during RSV season. Palivizumab is recommended for infants <2 yr of age with chronic lung disease (bronchopulmonary dysplasia) or prematurity. Meticulous handwashing is the best measure to prevent nosocomial transmission. 6. MATERIALS FOR METHODOLOGICAL BACKGROUND OF THE WORKSHOP 6.1. Quiz 1. What is the diagnosis and differential diagnosis for the most common acute respiratory infections of the upper respiratory tract in children? 2. What is the etiology of acute bronchitis? 3. What is the diagnosis and differential diagnosis for acute bronchitis? 4. What is the treatment approach for acute bronchitis? 5. What is the diagnosis and differential diagnosis for bronchiolitis? 6. What are the complications for bronchiolitis? 7. What is the treatment for bronchiolitis? 8. What is follow-up in bronchiolitis ? 6.2. Multi-choice questions 1. Acute bronchitis is more frequent in: A. The first year of life B. Newborn period C. Preschool age* D. School age E. Teenagers 6.3. The case report On admission to the hospital, the physicianobserved the child aged 8 months with fever, rhinirrhea and cough. On physical examination he revealed hoarseness, tachypnea with usually shallow respirations, tachycardia, nasal flaring, retractions and hyperinflation, wheeze, increased expiratory phase . 1. What is the diagnosis? 2. What is the plan of investigations? 3. What is the treatment plan? Suggested reading 1. Nelson Textbook of Pediatrics, 2-Volume Set, 20th ed. by Kliegman R.M., Bonita M.D. Stanton MD, Geme J.S., Nina F Schor MD / Elsevier Inc., 2016. P. 2057-2061. 2. Daniel Bernstein, Steven P. Shelov. Pediatrics for medical students. - USA: Lippinkot Williams & Wilkins. – 2008. - 650 p. 3. Janette B. Benson. Diseases and Disorders in Infancy and Early Childhood / Janette B. Benson Marshall M. Haith. - Academic Press, 2009 - 424 p. Additional reading 1. Lecture:Bronchitis. Upperrespiratorytractinfections 2. Pediatric Skills /Jean W. Solomon, Jane Clifford O`Brien/ . USA: Mosby. 2011. - 630 p. 3. www.bookfinder.com/author/american-academy-of-pediatrics 4. www.emedicine.medscape.com 5. http://www.nlm.nih.gov/medlineplus/medlineplus.html