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Case 1031: 'Does this chest infection require admission...?' Authors and Affiliations Katrina Dawes BA/BEd (UNSW) Professor Rakesh Seth Consultant Paediatrician Wagga Wagga Case Overview The case looks at some of the various causes of acute respiratory distress in the paediatric population and the management of community aquired pneumonia. Learning Objectives At the end of this clinical vignette, the student should know the: clinical features which suggest respiratory distress in children common causes of wheeze in children, and how to differentiate between these causes appropriate common investigations to conduct on a child presenting with wheeze pathogens responsible for viral pneumonia management of viral pneumonia and criteria for discharge in those who are treated as inpatients. Question 1 : MS Question Information: You are a resident working the night shift in the rural hospital emergency department when a woman brings in her 10 month year old daughter, Eden, as she has been †œsounding funny†• when she breathes and is breathing a bit quicker than usual. Her mother reports that Eden had a runny nose four days ago but it has cleared up, and she had a temperature of 37.4 degrees in the nighttime, but it settled with some paracetamol. Before taking further history you decide to examine Eden to assess the level of severity of her respiratory distress, and determine whether she needs admission. Question: Which of the following symptoms and signs indicate severe respiratory distress requiring urgent admission? Choice 1: A productive cough Score : -1 Choice Feedback: Incorrect, a productive cough may remain for days to weeks while an infection is resolving and in isolation is not a cause for urgent admission. Choice 2: O2 saturation of 96% on room air Score : -1 Choice Feedback: Incorrect, moderate respiratory distress is suggested by O2 saturations of 90-95% on room air and severe respiratory distress is indicated by O2 saturation <90% on room air or less than <92% on oxygen. Choice 3: Tachycardia (HR >180bpm) and tachypnoea (RR >70bpm) Score : 2 Choice Feedback: Correct, these are both signs of severe respiratory distress. Choice 4: Feeding <50% of regular amount Score : 1 Choice Feedback: Correct, a change in feeding pattern may be the only sign of respiratory distress in infants, who are too exhausted by the effort involved in feeding. Question 2 : MS Question Information: You find out from mum that Eden has still been eating and drinking and has had regular wet nappies and no bowel changes. She has been alert and interactive, although was grizzly through the day and more tired and cranky than usual. Mum reports she is also teething and mentions that it could just be due to that. Eden has had a cold once before, but this is the first time she has had any problems with her breathing. She has no allergies and there is no history of atopy in the family. Eden has had all the vaccinations recommended in the current immunisation schedule. You confirm this by checking her vaccination record, and notice that her height, weight and head circumference are also tracking along the 50th centile. On examination Eden has a respiratory rate of 75/min, BP of 90/60mmHg, HR of 175/min, temperature of 38.2 degrees (axillary) and has O2 saturation of 95% on room air. She is alert but irritable and has moist mucus membranes, good capillary refill, no peripheral or central cyanosis and no coryzal symptoms. She has no nasal flaring, grunting or stridor but does have a tracheal tug and subcostal and sternal recession with an occasional productive cough. On auscultation there is equal but reduced air entry on both sides, inspiratory crackles bilaterally and an expiratory wheeze throughout the chest. On systems review she has no inflammation or exudate on throat examination and examination of her ears shows a pearly white tympanic membrane, with no discharge, perforation or inflammation. There are no focal neurological signs or signs of meningism and her abdomen is soft and not tender. Question: Which of the following diagnoses should be considered at this stage? Choice 1: Asthma Score : -1 Choice Feedback: Incorrect. While a wheeze raises the possibility of a diagnosis of asthma, the fact that this is her first episode of wheeze and that it is associated with a recent cold, makes this diagnosis less likely. The negative history of any breathing problems in the past or any atopic conditions points to other diagnoses being more probable. Asthma is rare in infants. In an older child, asthma would be a more likely diagnosis if they have a history of recurrent wheeze, with diurnal variation, and triggers such as pets, dust and exercise and a personal or family history of atopy. In this instance a trial of asthma medications might be considered. Choice 2: Bronchiolitis Score : 1 Choice Feedback: The symptoms of tachypnoea, increased work of breathing, expiratory wheezing and crackles are consistent with the diagnosis of bronchiolitis. The course of her symptoms are also typical, with upper respiratory tract symptoms, followed by lower respiratory tract signs and symptoms on days two to three, being common. Choice 3: Viral pneumonia Score : 1 Choice Feedback: This is a reasonable provisional diagnosis, given her fever, cough and tachypnoea. The gradual onset and preceding upper airway symptoms as well as her diffuse, bilateral auscultatory wheeze point towards a viral infection. Choice 4: Pertussis Score : -1 Choice Feedback: This is unlikely given her clinical history. The typical presentation of an infection withBordetella Pertussis/whooping cough is a week of coryzal symptoms and low grade fever, followed a few weeks later by dry paroxysmal coughing fits (like a seal), with an inspiratory whoop. Choice 5: Bacterial pneumonia Score : 1 Choice Feedback: This is a reasonable provisional diagnosis. It can be difficult to distinguish bacterial pneumonia from viral respiratory infections clinically as the symptoms and signs of both conditions are nonspecific. Those with a bacterial infection may have faster onset of symptoms or more severe symptoms (higher temperatures, more lethargic/unwell) but clinical features cannot reliably differentiate the two. Choice 6: Viral laryngeotracheitis Score : -1 Choice Feedback: Viral laryngeotracheitis or croup is a viral infection of the upper airway, causing erythema and oedema of the tracheal mucosa. It†™s clinical presentation is typically a predominant harsh barking cough and symptoms consistent with upper airway obstruction, including inspiratory stridor and coryzal symptoms. Question 3 : FT Question Information: You look with dismay at the backlog of patients in the emergency department and at that moment your friendly on-call general practitioner walks towards you. He asks what the presentation is and whether the child needs admission. Question: Report the relevant findings to the on-call general practitioner, give your provisional diagnosis and justify whether you think inpatient or outpatient management is more appropriate for this presentation. Choice 1: null Score : 0 Choice Feedback: This is a 10 month old girl with a 2 day history of worsening dyspnoea and cough on the background of coryzal symptoms which have now resolved. She has been eating less and is still passing urine. Before this incident she has been otherwise well with no significant prenatal or birth history and is within normal range of growth parameters for her age. On examination she is alert but irritable and appears unwell. She is tachypnoeic with a respiratory rate of 75, tachycardic with a HR of 175bpm, febrile with an axilliary temperature of 38.2 degrees and O2 saturation of 95% on room air. She has no peripheral or central cyanosis. She has moderately increased work of breathing with tracheal tug and subcostal and sternal recession. There is an occasional productive cough but no stridor or grunting. On auscultation there is equal but reduced air entry, inspiratory crackles bilaterally and an expiratory wheeze throughout the chest. There are no other signs of focal infection, her ears and throat are clear. There are no focal neurological signs. My provisional diagnosis is acute bronchiolitis or community acquired pneumonia. I think she should be admitted for management given her age, her abnormal vital signs and her respiratory distress which has the potential to deteriorate further should she become exhausted. Question 4 : MS Question Information: The practitioner agrees with your decision. You decide that before you narrow down the diagnosis further you need to provide some supportive therapy to help Eden's respiratory distress. You realise that a chest X-ray cannot be organised until the following morning. Question: Which of the following management options should now be considered? Choice 1: Intravenous fluids Score : -1 Choice Feedback: As oral feeds are still being tolerated, and her hydration status is good, intravenous fluids are not required as part of immediate management. It is possible that Eden may need IV fluid replacement later in the admission if she does not tolerate oral intake due to her high respiratory rate. Choice 2: Broad spectrum antibiotics Score : 1 Choice Feedback: At this stage a chest X-ray (CXR) has not been obtained. A bacterial source of infection that accounts for her symptoms of moderate to severe respiratory distress have to be considered. Antibiotics should be commenced to account for a presumed bacterial pneumonia and prevent any possible deterioration. If a CXR excludes a pneumonia, the antibiotics may be ceased. Choice 3: Oxygen given via nasal prongs at 2L/min or simple facemask at 6 - 8 litres/min Score : 1 Choice Feedback: Oxygen should also be given to infants who show signs of hypoxia, increased work of breathing or increasing fatigue. Choice 4: Corticosteroids Score : -1 Choice Feedback: There is no indication for corticosteroids. These are useful in therapy for a confirmed asthmatic with symptoms of respiratory distress. Choice 5: Bronchodilator Score : 0 Choice Feedback: This can be considered in infants aged six to twelve months. A standard stat dose of salbutamol via a nebuliser may be trialled, and the patient assessed for a response before deciding whether to order more. Bronchodilators may be effective in bronchiolitis but this is rare. Question 5 : MS Question Information: You commence Eden on oxygen and antibiotics. Eden†™s O2 saturations improve to 97% and she appears more comfortable and you now consider the investigations you should order realising that they will not be back to you until the morning and that you may need to make decisions before you get them. Question: Which of the following are the most appropriate investigations to order? Choice 1: Full blood count Score : 1 Choice Feedback: This is not mandatory but may be warranted to evaluate if there is a bacterial aetiology. A neutrophilia on FBC would suggest bacterial pneumonia and can serve as a guide to the introduction of antibiotic therapy in children. Choice 2: Blood cultures (before commencing antibiotics) Score : 1 Choice Feedback: This is not necessary but can be justified if you are worried. A full blood count is already being collected, and would be reasonable to also collect blood cultures, as the patient is <1 year old has a fever >38 degrees and a focus of infection. This is to ensure the child is not septic. Choice 3: Urine dipstick Score : 1 Choice Feedback: There is a correlation between bronchiolitis and UTI's. A urine dipstick can be used as an appropriate diagnostic investigation. Choice 4: Lumbar puncture Score : -1 Choice Feedback: As the patient is not toxic, and there is a focus of infection identified, this is an unnecessarily invasive and distressing investigation to conduct at this point. If the child developed signs of toxicity a lumbar puncture would be indicated Choice 5: Nasopharyngeal aspirate with viral polymerase chain reaction Score : 1 Choice Feedback: Although this is not necessary if the diagnosis is clear, it can be considered for confirmation of the causative agent, to justify antibiotic therapy being withheld. Given the young age of the patient and the uncertainty of the diagnosis, this investigation can be justified. Choice 6: Chest X-ray Score : 2 Choice Feedback: This is mandatory. Choice 7: Spirometry Score : -1 Choice Feedback: Spirometry cannot be effectively conducted in a 10 month old infant. Choice 8: Serum lactate Score : 1 Choice Feedback: The presence of lactic acidosis will support the diagnosis of sepsis. Question 6 : FT Question Information: A PA chest X-ray is mandatory in this case to exclude bacterial pneumonia. It is not necessary if a diagnosis of bronchiolitis is clear, however it has a place when there is diagnostic uncertainty or an unusual disease course, to rule out other possible causes. According to the Paediatric Infectious Diseases Society of America Clinical Practice Guideline on Management of Community Acquired Pneumonia in children older than 3 months, "Chest radiographs (posteroanterior and lateral) should be obtained in all patients hospitalized for management of community-acquired pneumonia to document the presence, size, and character of parenchymal inﬕltrates and identify complications of pneumonia that may lead to interventions beyond antimicrobial agents and supportive medical therapy" An AP chest X-ray is performed the next morning. There is no one available to report on the film and you are asked by the general practitioner on-call to assess the X-ray and report it back to him, with your differential diagnosis. Question: Interpret the chest X-ray in a systematic manner and outline your provisional diagnosis based on your findings. Source: http://www.pemcincinnati.com/blog/wp-content/uploads/2013/02/Case-7.png Choice 1: null Score : 0 Choice Feedback: Sample answer: This is an AP radiograph, with adequate penetration and no rotation. The most notable feature is bilateral diffuse peribronchial infiltrates and increased haziness in the left upper zone. The trachea is midline. There are no fractures of the bones. The heart borders are distinct and there are no mediastinal masses evident. The cardiothoracic ratio cannot be assessed as it is an AP film, but the heart does not seem enlarged. The diaphragm borders are clear and the costrophrenic angles are sharp with no evidence of effusion. The lungs are equally expanded and there are no pneumothoraxes or masses in the lung fields. As already noted there are bilateral diffuse peribronchial infiltrates, with air bronchograms and peribronchial cuffing evident on both sides. These findings are consistent with bacterial bronchopneumonia, but should be correlated with clinical findings. Question 7 : MS Question Information: The general practitioner agrees with your assessment and decides to quiz you further on your knowledge of this condition. He asks you the following. Question: What are the common pathogens responsible for pneumonia in children of this age group? Choice 1: Parainfluenza Score : 0 Choice Feedback: This is not the most common, although it is responsible for some cases pneumonia in children. Choice 2: Cytomegalovirus Score : -1 Choice Feedback: This is not correct. Choice 3: Measles Score : -1 Choice Feedback: This is not correct. Choice 4: Human metapneumovirus Score : 0 Choice Feedback: This is not correct, although this virus is associated with viral LRTI in asthmatic children. Choice 5: Respiratory syncytial virus Score : 1 Choice Feedback: Correct. This is the most common cause of viral pneumonia in infants <5 years. Choice 6: Adenovirus Score : 1 Choice Feedback: Correct. Viruses are an important cause of pneumonia in this age group and adenovirus, enterovirus, rhinovirus, and coronavirus should all be considered - but they are less common than respiratory syncytial virus. Choice 7: Influenza Score : 1 Choice Feedback: This is not the most common, although it is responsible for some cases pneumonia in children. Choice 8: Streptococcus pneumoniae Score : 2 Choice Feedback: The most common bacterial form of pneumonia. Choice 9: Haemophilus influenzae Score : 2 Choice Feedback: Correct. This is a common bacterial form of pneumonia. Choice 10: E. coli Score : -1 Choice Feedback: Incorrect. E. coli is not often responsible for respiratory tract infections. Choice 11: Staph aureus Score : 0 Choice Feedback: Can be a community-acquired pneumonia in a population colonized with MRSA. Choice 12: Pseudomonas aeruginosa Score : -1 Choice Feedback: Hospital-acquired pneumonia. Choice 13: Klebsiella pneumoniae Score : -1 Choice Feedback: Incorrect. This is only seen in neonates or immunocompromised patients. Question 8 : MS Question Information: You explain the diagnosis to Eden†™s mother, who is extremely worried and has many questions. She wants to know the potential complications of pneumonia so she can watch out for them. Question: Which of the following are complications of pneumonia? Choice 1: Pleural effusion Score : 1 Choice Feedback: This is more commonly associated with bacterial pneumonia but can also occur with adenovirus infection. Choice 2: Respiratory failure Score : 1 Choice Feedback: Despite basic supportive measures, children can develop worsening hypoxaemia and hypercarbia and require intubation and mechanical ventilation. Worsening O2 saturations despite supportive therapy are an indicator for an arterial blood gas to determine if respiratory failure is occurring (PaCO2 >50mmHg or PaO2 <60mmHg). Choice 3: Apnoeas Score : 1 Choice Feedback: This is a more common complication in infants less than 8 weeks old or those who were premature with associated lung disease, however it can affect any child and is most common in those infected with respiratory syncytial virus. Choice 4: Dehydration Score : 1 Choice Feedback: This is a common complication which can occur as a result of tachypnoea, cough and decreased feeding. Choice 5: Cystic fibrosis Score : -1 Choice Feedback: This is incorrect. Cystic fibrosis is an autosomal recessive inherited disorder, which is due to a gene mutation on the long arm of chromosome 7. There is a defect of the cystic fibrosis transmembrane conductance regulator (CFTR) which causes a failure of opening of the chloride channel in epithelial cells. This results in decreased excretion of chloride into the airway lumen and an increased reabsorption of sodium into the epithelial cells. This decreased excretion of sodium means there is less excretion of water and increased viscosity and tenacity of airway secretions. Having pneumonia does not cause a person to develop CF, however a common presentation of CF is recurrent respiratory infections, due to loss of innate immunity from impaired mucus clearing. For this reason children with repeat presentations to hospital with respiratory infections should be tested for CF. Choice 6: Lung abscess Score : 1 Choice Feedback: Chronic or subacute lung abscesses can follow an inadequately treated pneumonia. Abscesses also develop during the course of specific pneumonias, particularly when the infecting agent isStaph.aureus or Klebsiella pneumoniae. Choice 7: Epiglottitis Score : -1 Choice Feedback: This is incorrect. Epiglottitis is a bacterial infection caused byHaemophilus Influenzae B. Choice 8: Bronchiectasis Score : -1 Choice Feedback: Incorrect. This is not a complication of pneumonia. Congenital predispositions include bronchotracheomalacia. Question 9 : MS Question Information: Once you have addressed Eden's mothers concerns, you start to organise the necessary management for her admission. She has already been given oxygen, which is keeping her saturation level at 96%, and she has had necessary investigations carried out. Question: Which of the following are also important aspects of her management, given your working diagnosis of community-acquired bacterial pneumonia? Choice 1: Nebulised adrenaline Score : -1 Choice Feedback: This is not indicated. Nebulised adrenaline is effective in the treatment of bronchospasms due to asthma and for viral croup Choice 2: IV benzylpenicillin Score : 2 Choice Feedback: This is correct. This is given on the premise Eden most likely has community-acquired pneumonia and that the causative agent is susceptible to benzylpenicillin. Choice 3: Insertion of an intravenous cannula Score : 1 Choice Feedback: This would be appropriate management given that she is to be treated as an inpatient and may need administration of fluids if she becomes to exhausted to feed. Choice 4: Analgesia and antipyretics Score : 1 Choice Feedback: These are not required but can be used to keep the child comfortable if they are distressed. Choice 5: Steam therapy Score : -1 Choice Feedback: There is no evidence to support the use of steam therapy in management of pneumonia. Choice 6: Ribivarin (antiviral) Score : -1 Choice Feedback: Incorrect, the most common cause of viral pneumonia is RSV which ribivarin has minimal/no effect against. It also has toxic side effects. Choice 7: IV ceftriaxone/cefotaxime Score : 1 Choice Feedback: Partially correct. This is a second-line treatment used if the child is not responding appropriately to the IV benzylpenicillin or if the child is very sick at presentation. Question 10 : FT Question Information: Eden makes significant improvement over the next two days, while you are quietly celebrating your success with managing her treatment effectively, her mum approaches you to find out when you think they will be able to go home. Question: Outline the clinical parameters which suggest a patient is safe for discharge. Choice 1: null Score : 0 Choice Feedback: A patient is eligible for discharge when they have documented overall clinical improvement, including level of activity, appetite, and decreased fever for at least 12†“ 24 hours. They must have consistent pulse oximetry measurements >94-95% in room air for at least 12†“ 24 hours with no signs of respiratory distress and must have stable baseline mental status. They should be able to tolerate any anti-infective regimen required and the practitioner should be confident that the guardian can manage careful observation at home, comply with therapy, and attend necessary follow-up appointments. Synopsis Eden is discharged home and makes a full recovery. A few weeks later you receive a lovely card thanking you for your hard work in looking after her. Lower respiratory tract infections are a leading cause of morbidity or mortality in the paediatric population. They most often affect children less than 2 years of age. Nearly 80% of pneumonia in the paediatric population has a viral aetiology with RSV being the most common. The pathogens responsible for infection are dependent on the age group of the child with neonates most commonly affected by gram positive cocci such as B Streptococcus and Staphlococcus aureus, or gram negative enteric bacilli in neonates, and respiratory syncytial virus, Parainfluenza, Influenza and Adenovirus are the most common cause in infants aged 1 month to 5 years. Bacterial agents in this age group include Haemophilus influenza, Streptococcus pneumoniae and Staphylococcus aureus. Although bacterial pneumonias are less common, they should be considered in the context of an abnormal chest X-ray, an abnormal white cell count and the severity of the illness warrants that the patient should be started on a regimen including IV benzylpenicillin and a second/third-generation cephalosporin. The clinical symptoms of pneumonia may include prodromal non-pulmonary symptoms such as fever, headache and malaise. There may also be preceding coryzal symptoms followed by chest pain or abdominal pain (particularly if a lower lobe is effected). Clinical signs may include productive cough, increased respiratory effort demonstrated by one or more of the following: nasal flaring, grunting, head bobbing, tracheal tug, intercostal and/or subcostal recession, tachypnoea and shallow breathing. On auscultation findings can include crackles, decreased breath sounds, increased fremitus, dullness to percussion and wheeze. There are no clinical signs to distinguish bacterial from viral pneumonia in children, although bacterial pneumonia may have more severe symptoms of fever and distress. Inpatient treatment is indicated for children with moderate to severe disease. This is indicated by respiratory distress (respiratory rate >70 breaths/minute for infants <12 months of age and >50 breaths per minute for older children; subcostal and intercostal recession, tracheal tug, nasal flaring, head bobbing, apnoea; grunting) O2 saturation <90% on room air, hypoxaemia despite optimal O2 therapy, respiratory failure on ABGs (PaCO2 >50mmHg, or PaO2 <60mmHg), signs of toxicity (high fever, drowsiness, lethargy, shock) The level of investigations required depends on the certainty of the practitioners diagnosis based on clinical history and examination findings. Bronchiolitis and viral pneumonia are both diagnosis which are made clinically, however a nasopharyngeal aspirate with PCR can be useful to confirm the diagnosis, and a chest X-ray and full blood count with cultures are useful to help determine if a bacterial aetiology exists. This decision must be based on the severity of the illness and the clinical presentation. Chest Xray findings in viral pneumonia may show peribronchial infiltrates, however there may also be no X-ray changes. Potential complications of viral pneumonia include pleural effusion, respiratory failure, apnoea, dehydration and secondary bacterial infection. The principles of treatment of a viral pneumonia include: - Relieving respiratory distress. This is done with O2 therapy via nasal prongs at 2 litres per minute or simple facemask at 6 to 8 litres per minute. Fluids may also be given as part of supportive therapy if the child is not feeding or is dehydrated. Analgesia and antipyretics may be required to relieve distress. - Ensuring adequate oxygenation: supplemental oxygen usually ensures this, however intubation and ventilation may be required in respiratory failure occurs. - Preventing and treating complications. This involves monitoring for worsening symptoms and signs of bacterial infection, effusions or toxicity Discharge can be considered in a child who shows overall clinical improvement, including activity, appetite, and decreased fever for at least 12†“ 24 hours. There must be consistent pulse oximetry measurements >95% in room air for at least 12†“ 24 hours with no signs of respiratory distress and stable baseline mental status. The practitioner should be confident that the guardian can manage careful observation at home, comply with therapy, and attend necessary follow-up before discharge is arranged Acknowledgements: We gratefully acknowledge Assistant Professor Brad Sobolewski for granting permission for the use of the X-ray presented in this case Resources: National Asthma Council Australia. Australian Asthma Handbook, Version 1.0. National Asthma Council Australia, Melbourne, 2014. Website. Available from: http://www.asthmahandbook.org.au Royal Children†™s Hospital Melbourne †œPneumonia Guidelines†•, http://www.rch.org.au/clinicalguide/guideline_index/Pneumonia_Guideline/ Bradley J, Byington C et al, The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America Barson W, †œPneumonia in children: Epidemiology, pathogenesis, and etiology†• UpToDate, Kaplan S (Ed), UpToDate, Waltham, MA. (Accessed on November 25, 2013.) †œInfants and Children: Acute Management of Bronchiolitis †“ Clinical Practice Guideline†•, NSW Ministry of Health, January 2012 †œChildren and Infants with Fever - Acute Management†• NSW Ministry of Health, October 2010 Roberton D.M & South M. Practical Paediatrics, 6th Edition. Churchill Livingstone Elsevier UK. 2006 Walsh B et al, Perinatal and pediatric respiratory care 3rd Edition, Saunders Elsevier, Missouri, 2010 Starr, M, †œCommunity acquired pneumonia†• in Textbook of paediatric emergency medicine Peter Cameron (Ed), Churchill Livingstone Elsevier, 2006 Kilham H et al, Paediatrics manual : the Children's Hospital at Westmead handbook, North Ryde : McGraw-Hill, 2009. Updated July 2016