Respiratory Infections

Upper respiratory
tract infection

Laryngeal and
tracheal infections
(Stridor)

Bronchiolitis

Bronchitis

Viral bronchitis (mainly)

(common cold, Influenza,
measles)

Lobar
pneumonia

Bacterial bronchitis
(Bordetella pertussis,
Mycoplasma pneumoniae)

Interstitial
pneumonia

bronchopneumonia

Acute

Chronic

1-infection

viral croup
(Viral
laryngotracheitis)

Pneumonia

2-allergy

Acute epiglottitis

Bacterial croup
Diphtheritic laryngitis,
Bacterial tracheitis
(pseudomembranous croup)

3-Mechanical

Acute spasmodic
laryngitis
(mid-night croup)

Allergic laryngeal
oedema
(angioedema)

4-Metabolic

Laryngeal foreign
body

Retropharyngeal
abscess

Hypocalcaemia
stridor

Congenital
Congenital laryngeal stridor
(Laryngomalacia), congenital
papilloma or hemangioma

Common cold
(acute rhinitis ,
coryza)

Sore throat
(pharyngitis)
& (tonsillitis)

Acute otitis
media

sinusitis

Acquird
Forign body &
tumor

1- Upper respiratory tract infection (URTI):

* The commonest presentation is a child with a combination of a nasal discharge and blockage, fever, painful throat , earache & sometime Cough.
* Approximately 80% of all respiratory infections.

note

Investigation &
treatment

Clinical feature

Definition, etiology &

pathophysiology

Common cold (acute rhinitis , coryza)

Sore throat (pharyngitis & tonsillitis)

* This is the commonest infection of

childhood.
* commonest pathogens are viruses
Rhinoviruses, corona viruses and RSV
* 6-12 attacks per year

* mainly due to viral infection (mostly

Adenovirus ) then bacterial infection (mostly
group A -hemolytic Streptococcus (in older
children))
* tonsillitis is a form of pharyngitis but with
intense inflammation of tonsils with purulent
exudates.
*EBV (infectious mononucleosis) is also
common to cause tonsillitis

1- nasal discharge (clear or mucopurulent)

2- nasal blockage.
3- low grade fever.
4- sore throat.
5- cough
6- sneezing & nasal tone of voice.
7- mouth breathing.
8- headache

1- fever.
2- sore throat / dysphasia
3- cervical lymph nodes are enlarge & tender.
4- pharynx & soft palate are inflamed.
5- if tonsils are include,red and/or swollen tonsils
white or yellow follicles on the tonsils (pus) or
pseudomembrane.
6-headache.
7- abdominal pain.

1- symptomatic therapy and have no specific

curative treatment (self-limiting)
2- Fever and pain are best treated with
paracetamol or ibuprofen.
3- for nasal block (ephedrine nasal drops)

1- symptomatic therapy (antipyretic, fluid)

2- Antibiotics (often penicillin, or erythromycin if
there is penicillin allergy) for 10 days to
eradicate the organism to prevent Rheumatic
fever.

*Complication:
1- recurrent fever 2- pneumonia
3- sinusitis 4- otitis media 5-adenitis
6- conjunctivitis 7-pharyngitis
*the common cold viruses are (rhinovirus,
influenza, coronavirus, respiratory syncytial
virus (RSV)).

* Amoxicillin is best avoided as it may cause a

widespread maculopapular rash if the
tonsillitis is due to infectious mononucleosis.
* It is not possible to distinguish clinically
between viral and bacterial tonsillitis.
(next page: differences between viral &
bacterial tonsillitis.)

Acute otitis media

* is mainly an obstructive disease, when Eustachian
tube becomes obstructed by: edema of mucous
memb. During URTI & enlarged adenoids (transudate
collection in middle ear infected by organism ascending
through Eustachian tube) .

* commonest at 6-12 months of age.

* mostly by purely viral & may cause 2ry bacterial inf.
* virus mostly by RSV and rhinovirus
* bacteria mostly by pneumococcus & H.influenza
1- fever .
2- pain in the ear .
3-irritability and head rolling .
4-by otoscope to examine the tympanic membrane:
bright red with loss of the normal light reflection and
bulging or perforated ear drum with pus.
5- sharp pain , when pressing on mastoid process.
* For recurrent ear infections, can lead to otitis media
with effusion (glue ear or serous otitis media).
Children are asymptomatic apart from possible
decreased hearing. The eardrum is seen to be dull
and retracted, often with a fluid level visible
1- resolve spontaneously 80% of acute otitis media.
2- Antibiotics (amoxicillin): shorten the duration of
pain but doesn't reduce the risk of hearing loss
3- drainage of middle ear
4- symptomatic therapy analgesic & antipyretic
5- myringotomy (grommet) & adenoidectomy: in
sever O.M or if no response to medicine
* Otitis media with effusion(OME) is the most common
cause of conductive hearing loss in children and can
interfere with normal speech development and
result in learning difficulties in school.
* Infants and young children are prone to OM because
their Eustachian tubes are short, horizontal and
function poorly
* Chronic suppurative O.M: is perforated tympanic
membrane With active bacterial inf.for several week
* rare complications: mastoiditis and meningitis

Sinusitis

* occur with viral URTIs but

not disappear after the
nasal inf. Has subsided.
* may cause 2ry bacterial
Infection.

1- fever
2- tenderness & swelling
over involved sinuses
3- mucopurulent nasal
Discharge
4- headache

1- x-ray: clouding of the

affected sinuses.
2- antibiotic.
3- symptomatic therapy
analgesic & antipyretic

Causes of persistant
sinusitis:
1-hypertrphied adenoids
2-deformiy of nasal septa
3-Allergy
4-recurrent rhinitis

Indications for the removal of both the tonsils and adenoids are controversial but
include:
1. otitis media with effusion with hearing loss, when it gives a small additional
benefit to the insertion of grommets (ventilation tubes).
2. obstructive sleep apnoea (an absolute indication).
3. In young children the adenoids grow proportionately faster than the airway, so
that their effect of narrowing the airway lumen is greatest between 2 and 8 years
of age. They may narrow the posterior nasal space sufficiently to justify
adenoidectomy.
The indications for tonsillectomy are controversial but include:
1. recurrent tonsillitis (as opposed to recurrent URTIs) tonsillectomy reduces the number of episodes of
tonsillitis by a third, e.g. from three to two per year
2. a peritonsillar abscess (quinsy)
3. obstructive sleep apnoea

Common cold symptoms

differences between viral & bacterial tonsillitis

bacterial

viral

Onset

Sudden

Gradual

Course

sever

mild

Fever

high

moderate

Cough

late

early

WBCs

> 10,000

< 10,000

Follicles &/or membrane

both

+/- membrane

Cervical lymph node

+/-

Complication as quinsy
(Peritonsillar abscess)

+++

+/-

Otoscope for otitis media

Sore throat

Sinusitis

2( Laryngeal and tracheal infections:

* The mucosal inflammation and swelling produced by laryngeal and tracheal infections can rapidly cause life-threatening obstruction of the airway in young children.
* characterized by: stridor on inspiration, hoarseness due to inflammation of the vocal cords, a barking cough like a sea lion and dyspnoea.
1-infection
Croup

Acute epiglottitis

Definition, etiology &

pathophysiology

* The commonest cause of stridor in childhood & infancy.

* 95% of laryngotracheal infections.
* Etiology: - mainly viral (mostly Parainfluenza, RSV, Influenza, Adenovirus, Measles,
Metapneumovirus.)
- Bacterial: 1ry cause Diphtheria
ry
2 to viral inf. most common Staphylococcus aureus,
Streptococcus pneumoniae & H. influenza

* Less common but more serious than viral croup.

* Is a life-threatening emergency due to respiratory obstruction.

* Age: 6 months - 6 years of age but the peak incidence is in the second year of life.
* Croup is commonest in the autumn and early winter.

* Age: 1yrs - 6yrs in children, but can affects all age groups.

(Hib immunization in infancy has led to a decrease of over 99% in the incidence of
Epiglottitis and other invasive H. influenzae type b infections.)

Clinical feature

* There is intense swelling of the epiglottis and surrounding tissues associated with
Septicemia.

1- onset: over days

2- typical feature: harsh, rasping inspiratory stridor - barking cough - hoarseness
3- usually preceded by low grade fever and coryza. (for 1-2 days)
4- start & worse at night.
5- if sever: marked tachepnea, intercostals chest recession, cyanosis & continuous stridor

1- onset: over hours, sudden.

Investigation & treatment

*There is mucosal inflammation and secretions affecting the larynx, trachea and bronchi, but
edema in subglottic area is dangerous in young children may cause critical narrowing of the trachea

* Etiology: Bacterial infection, mostly H. influenza type B.

1- mild: can usually be managed at home, by keep him at rest, use of steam of hot
shower in close bathroom and use routinely of steroid (Oral dexamethasone ,oral
prednisolone and nebulised steroids, budesonide) can reduce the severity and
duration of croup and the need for hospitalization.

1- Urgent hospitalization & start treatment without delay.

2- transferred the child to ICU and operation room in presence of senior anesthetist
,pediatrician and ENT surgeon in case of obstruction to do tracheostomy if needed
3- Intubated under controlled conditions with a general anesthetic.
4- Urgent tracheostomy is life-saving.
5- Only after the airway is secured , do blood culture and IV antibiotics such as
Cefuroxime (zinacef) (2nd generation cephalosporin) for 2-3 days.
6- With appropriate treatment, most children recover completely within 2-3 days.

2- sever: need for hospitalization: Nebulised epinephrine (adrenaline) , humidified O2 ,

(When saturation of <93% nebulised epinephrine (adrenaline) with oxygen by face
mask and closely monitored) , steroid therapy & few cases require tracheal
intubation. If no response: tracheostomy is life saving.

2- high fever - toxic-looking child - sore throat (prevent speaking or swallowing) - saliva
drools down the chin soft, whispering inspiratory stridor and rapidly dyspnea.

cough is minimal or absent

3- over hours the child sits immobile, upright, with an open mouth to optimise the airway.

0note

Bacterial tracheitis (pseudomembranous croup):

caused by infection with Staphylococcus aureus or H. influenzae
Rare but dangerous. Similar to severe viral croup except that the child has a high fever, appears
toxic, loud stridor and has rapidly progressive airways obstruction with copious
thick airway secretions. IV antibiotics and intubation and ventilation if required.

Diphtheritic laryngitis:
Gradual onset, mild sore throat, low grade fever, grayish membrane formed On tonsils extending to
the larynx, toxemia & enlarge cervical L.N, in addition to typical feature.
Death occur from sever obstruction unless tracheostomy performed + Penicillin & antitoxin

* Don't Attempts to lie the child down or examine the throat with a spatula or
perform a lateral neck X-ray as they can lead to total airway obstruction and death
So, must be performed in the operating room in presence of anesthetist to do
urgent tracheostomy if needed
* Direct laryngoscope (in the operating room) show red & swollen epiglottis.
* As with other serious H. influenzae infection, prophylaxis with Rifampicin is offered
to close household contact

3-Mechanical

2-Allergy
Acute spasmodic laryngitis (mid-night croup):
* Acute, self limited & usually recurrent laryngeal spasm. The etiology is
unknown, but may be due to emotional disturbance.
* Clinical feature:
sudden onset at midnight of barking cough, hoarseness, stridor and respiratory
distress with tachycardia. The attack usually subsides after 1-4 hours. It
may occur in the same night or the next 1-2 nights.
* Treatment:
Humidification (steam from hot shower) is usually sufficient.

Allergic laryngeal oedema (angioedema):

* May associated with other evidences of allergy as urticarial skin rash. It improves
by epinephrine or hydrocortisone.

Chronic
Congenital laryngeal stridor (Laryngomalacia):
* Its called Laryngomalacia or Tracheomalacia. Stridor occurs
immediately at or few days after birth.
* Clinical features:
- More common in boys.
- Noisy respiratory & stridor start immediately at or few days after.
* Diagnosis:
- Direct laryngoscope.
- the condition improve spontaneously by the age of 1 year.
Congenital web or papilloma: need surgical removal.

Laryngeal foreign body:

* Very important in pediatric ages. The obstruction is mechanical followed
by inflammation.

4-Metabolic
Hypocalcaemia stridor:
* the patient is rachitic. Tetany is usually precipitated by infection. The
stridor is usually precipitated by crying or any irritation of the child (revise
Tetany)

Clinical features of croup (viral laryngotracheitis) and epiglottitis

Croup

epiglottitis

Onset

Over days

Over hours

Preceding coryza

Yes

No

Cough

Severe, barking

Absent or slight

Able to drink

Yes

No

Drooling saliva

No

Yes

Appearance

Unwell

Toxic, very ill

Fever

<38.5 C

>38.5 C

Stridor

Harsh, rasping

Soft, whispering

Voice, cry

Hoarse

Muffled, reluctant to speak

3&4( Acute Bronchitis and Acute Bronchiolitis:

Definition, etiology &

pathophysiology

Acute Bronchitis
* Inflammation of the bronchial mucosa, usually associated with inflammation of the

trachea i.e. traceobronchitis, producing a mixture of wheeze and coarse crackles.

The mucosa is red & swollen hemorrhagic spot, covered by tenacious mucus, at times
its purulent.
* Etiology: mainly viral (common cold viruses - influenza - measles)
Bacterial (Bordetella pertussis - H.influenza - Mycoplasma pneumoniae)

note

Investigation &
treatment

Clinical features

Whooping cough (pertussis)

Acute Bronchiolitis
* the commonest serious respiratory infection of infancy.
* 2-3% of all infants are admitted to hospital with the disease each year during annual winter
epidemics; 90% are aged 1-9 months (bronchiolitis is rare after 1 year of age).

* Etiology: RSV (80%), Human metapneumovirus & Parainfluenza & adenovirus

* pathophysiology: infectioninflamation of bronchiolesmucous secretion &edema
generalized bronchiolar obstructionair trapping & hyper inflation of lung alveoli
(gas exchange is disturbed with the result of hypoxia and in severe case of hypercapnia)
* common in the 1st 2 years of life with peak incidence around 6 months

1- catarrhal phase: a week of coryza.

2- paroxysmal phase: - paroxysmal or spasmodic cough followed by a characteristic
(lasts 3-6 weeks)
inspiratory whoop worse at night and may culminate in vomiting.
- the child goes red or blue in the face, and mucus flows from the
nose and mouth.
- Epistaxes and subconjunctival haemorrhages can occur after
vigorous coughing.
3- convalescent phase: The symptoms gradually decrease, but may persist for many
months.

A- start by mild URTI:

1- sharp, dry cough 2- no fever or low-grade fever. 3- rhinitis
B- then gradual development of respiratory distress:
1- hyperinflation of the chest (sternum prominent - liver displaced downwards)
2- subcostal and intercostal recession
3- fine end-inspiratory crackles 4- high-pitched wheezes - expiratory > inspiratory
5- tachycardia
6- cyanosis or pallor.
7- dyspnea & tachypnoea

1- Culture of a per-nasal swab: can early identify the organism of this disease.
2- Marked lymphocytosis (>15 109/L).
3- CXR: may show increase in bronchial marking

1- immuonofluroscent technique: RSV can be identified rapidly on nasopharyngeal secretions

demonstrating binding of a fluorescent antibody.
2- A chest X-ray: shows hyperinflation of the lungs due to small airways obstruction, air
trapping and opacities area often focal atelectasis.
3- Blood gas analysis: in severe cases, shows lowered arterial oxygen and raised CO2 tension

1- Erythromycin eradicates the organism, it symptoms only if started in catarrhal phase.

2- prophylaxis erythromycin: for close contacts.
3- Immunisation: the risk of developing pertussis & the severity of disease
* The whoop may be absent in infants, but instead apnoea is a feature at this age.
* Bronchitis in children is very different from the chronic bronchitis of adult. In children,
cough and fever are the main symptoms.

1- Hospitalization.
2- Humidified oxygen: to relieve cyanosis, dyspnea & irritability.
3- IV fluid: to prevent dehydration.
4- no response to antibiotic, bronchodilators & corticosteroid
5- Ribavirini ( Virazole ) is antiviral agent, recently they use it in severe cases
6- Mechanical ventilator: in severe cases with respiratory failure

* The cough may persist for about 2 weeks, or longer with pertussis or Mycoplasma inf.
* There is no evidence that antibiotics, cough suppressants or expectorants speed recovery
because most of this disease caused by virus .
* Using antibiotics in patients who do not have bacterial infections promotes the
development of antibiotic-resistant bacteria, which morbidity and mortality. Youve to
be sure that is bacterial inf. Before use the antibiotic.
* Complications: pneumonia, convulsions and bronchiectasis, are uncommon.
* clinical picture of bronchitis : - cough (most constant symptom) start dry then productive
( In general)
- ronchi (most important sign)
- fever: milde if present

* Infants born prematurely who develop bronchopulmonary dysplasia and infants

with congenital heart disease are most at risk from this disease.
* Feeding difficulty associated with increasing dyspnoea is often the reason for
admission to hospital.
* on examination: probably you will find hyper inflated chest with tachepnea,
prolonged expiration & uses of accessory muscle, palpable ronchi, diminish tectile
vocal fremitus, hyper resonance, diminish air entry, vesicular breathing with
prolonged expiration and generalized wheezing and fine crepitating
* total WBC count is normal
* respiratory failure is the cause of death in this case.

Differential Diagnosis of Bronchiolitis:

1. Bronchial asthma: in asthma recurrent of the attacks is
the rule, family history, eosinophilia are present in
atopic cases and has good response to
bronchodilator. However, bronchiolitis doesn't.
2. Congestive heart failure.
3. Foreign body aspiration.
4. Bronchopneumonia with spasm.
5. Pertussis
6. Cystic fibrosis
7- Gastro esophageal reflux