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‘Tis the Season: Croup, bronchiolitis, and influenza

‘Tis the Season: Croup, bronchiolitis, and influenza. 1. Recognize differences between the pediatric and adult airway 2 . Recognize respiratory distress in the pediatric population 3 . Distinguish among croup, bronchiolitis, and influenza in pediatric patients

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‘Tis the Season: Croup, bronchiolitis, and influenza

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  1. ‘Tis the Season:Croup, bronchiolitis, and influenza

  2. 1. Recognize differences between the pediatric and adult airway • 2. Recognize respiratory distress in the pediatric population • 3. Distinguish among croup, bronchiolitis, and influenza in pediatric patients • 4. Summarize approaches to management of the above viral respiratory illnesses Objectives

  3. https://medicine.umich.edu/sites/default/files/content/downloads/Bradin%20Stuart%20October%204%20Plenary-Fever%2C%20Croup%20and%20Bronchiolitis%20in%20Kids_0.pdfhttps://medicine.umich.edu/sites/default/files/content/downloads/Bradin%20Stuart%20October%204%20Plenary-Fever%2C%20Croup%20and%20Bronchiolitis%20in%20Kids_0.pdf

  4. Pediatric Assessment Triangle Sick or Not Sick?

  5. Increased work of breathing: • Location? • Severity? • Associated breath sounds? Nasal flaring Upper resp tract disorders Lower resp tract disorders

  6. Abnormal breath sounds

  7. Croup

  8. Prodromal symptoms mimic URI • Fever may be low-grade • Barky cough and stridor are common (90%) • Hoarseness and retractions also may occur Croup Distinctive “barking” cough is caused by swelling of tissue around the larynx and trachea

  9. Croup/Laryngotracheobronchitis • Most common cause for stridor in a febrile infant • Typically occurs < 2 yr of age (6 mo to 6 yr; mean 18 mo) • Male predominance 2:1 • Seasonal: late fall, early winter • Viral etiology: • Parainfluenza (60%) • Influenza A • RSV • Adenovirus • Coxsackie virus • Mycoplasma pneumoniae Symptoms typically last 4-7 days; often worse at night

  10. Croup: Diagnosis Steeple sign

  11. Indicated for mod-to-severe distress: retractions, stridor at rest Croup: Management * * Steroids associated with shorter duration of illness, decreased rates of hospitalization and intubation, and shorter hospital stays

  12. 4-kg, 3-month-old, former 31-weeker w/ short NICU stay • 2-day hx of cough and nasal congestion • Breathing “funny” per mom • Temp: 38 C, HR: 195, RR: 80, O2 sat: 93% ORA • On exam: • Pale, ill-appearing, with slightly sunken eyes and dry mouth • No stridor, but thick nasal secretions and nasal flaring • Intercostal and subcostal retractions • Diffuse wheeze and rhonchi • No mumur; tachycardic • Delayed cap refill; cool, mottled skin • Per mom: Baby “turned blue” but improved when she picked him up and rubbed his back Case 2

  13. Viral infection of medium and small airways • RSV 85% • Influenza A, parainfluenza, rhinovirus, adenovirus • Peak: winter to early spring • Most children infected by 3 yr of age • Peak incidence: 2-6 mo • Highly contagious • RFs for severe disease: • Young age • Prematurity • Underlying lung disease • Immunodeficiency Bronchiolitis

  14. Supportive Care • Fluids • O2, when appropriate • Monitoring • Nasal suctioning • Ventilatory support Prevention • Premature infants • Palivizumab: RSV monoclonal antibody- shown to prevent RSV hospitalizations and intensive care unit admissions in high-risk infants. Management

  15. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis Ralston et al: Pediatrics 134(5): 2. Clinicians should not administer albuterol (or salbutamol) - Evidence Quality: B; Recommendation Strength: Strong Recommendation 3. Clinicians should not administer epinephrine - Evidence Quality: B; Recommendation Strength: Strong Recommendation 4a. Nebulized hypertonic saline should not be administered in the emergency department - Evidence Quality: B; Recommendation Strength: Moderate Recommendation 4b. Clinicians may administer nebulized hypertonic saline [inpatient] - Evidence Quality: B; Recommendation Strength: Weak Recommendation 5. Clinicians should not administer systemic corticosteroids [in any setting] - Evidence Quality: A; Recommendation Strength: Strong Recommendation

  16. Continued 6a. Clinicians may choose not to administer supplemental oxygen if the oxyhemoglobin saturation exceeds 90% (Evidence Quality: D; Recommendation Strength: Weak Recommendation [based on low level evidence and reasoning from first principles]) 7. Clinicians should not use chest physiotherapy (Evidence Quality: B; Recommendation Strength: Moderate Recommendation) 8. Clinicians should not administer antibacterial medications to infants and children with a diagnosis of bronchiolitis unless there is a concomitant bacterial infection, or a strong suspicion of one (Evidence Quality: B; Recommendation Strength: Strong Recommendation) 9. Clinicians should administer nasogastric or intravenous fluids for infants with a diagnosis of bronchiolitis who cannot maintain hydration orally (Evidence Quality: X; Recommendation Strength: Strong Recommendation)

  17. Stats from 2017-2018 flu season: • US Deaths: >80K!; pediatric: 185 Native Americans and Alaskan Natives are at high risk for complications from influenza • Compared with other populations, NA/AN are at higher risk for complications, hospitalizations, and death • Flu and pneumonia rank among top 10 causes of death in NA/AN populations Influenza

  18. Thanks!

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