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ILLNESSES

• Pneumonia • RSV/Bronchiolitis • Influenza • Pertussis PEDIATRIC RESPIRATORY ILLNESSES

DR. AMANDA O’CONNOR DO INTERNAL MEDICINE/PEDIATRIC HOSPITALIST SEPTEMBER 29, 2015

PNEUMONIA

• History • Treatment • Exam • Inpatient • Outpatient • Imaging • Complications • CXR • Ultrasound • Labs PNEUMONIA • CBC, BMP • Sputum Cultures • Other Labs • ?Blood cultures

PNEUMONIA PNEUMONIA - EXAM

• 3-4/100 children under age 5 • Physical Exam Tachypnea – per WHO • Vitals • 201/100,000 get hospitalized Less than 2 months old: >60 • Greatest rate of hospitalization for those <1 y.o. • Mental Status 2 – 12 months: >50 • Lung Exam 1 – 5 years old: >40 • 525 children <15 y.o. died as a result of pneumonia Great than 5 years old: >20 in 2006 • Crackles • Decreased breath sounds • Whispered pectoriloquy • Egophony • Bronchophony • Tactile fremitus • Dullness to percussion • Cyanosis

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PNEUMONIA - DIAGNOSTICS PNEUMONIA - DIAGNOSTICS

• CXR – PA & Lateral • CBC • Hypoxemia or significant respiratory distress • In those with severe disease • Failed antibiotics therapy • Acute Phase Reactants: CRP, ESR, Pro-calcitonin • All inpatients • Maybe helpful in severe disease/complications to assess • Follow up CXR response to therapy • No clinical improvement in 48-72 hours after initiation of abx • Pulse oximetry – should be used in all patient with • Patients with complicated pneumonia with worsening distress, instability or continued fever pneumonia and suspected hypoxemia • 4-6 weeks after dx • Recurrent pneumonia in the same lobe • Lobar collapse on initial CXR • Suspected anatomic anomaly, chest mass or foreign body aspiration

PNEUMONIA - DIAGNOSTICS PNEUMONIA - DIAGNOSTICS

• Blood cultures • Sputum Cultures – Yes • Outpatient • Urinary antigens – No • Only in those who fail to demonstrate clinical improvement and in those who have progressive symptoms/clinical deterioration • Viral Pathogen Testing after initiation of abx • Influenza – yes • Inpatient • Other resp viruses • Moderate to severe presentation of bacterial CAP • Testing for Atypical Pneumonia • Complicated CAP • Positive blood cx – in an improving patient should NOT delay discharge • Repeat cultures???

PNEUMONIA - DIAGNOSTICS PNEUMONIA - MANAGEMENT

• Tracheal aspiration – should be obtained at the • Who gets hospitalized time of intubation for gram stain and culture • Any child/infant with Moderate to Severe CAP • Infants less than 3-6 months of age with suspected bacterial CAP – may benefit • Suspected or documented CAP caused by a pathogen with increased virulence such as CA-MRSA • Patients for who there is concern about careful observation at home or who are unable to comply with therapy or follow up.

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PNEUMONIA - TREATMENT

• Outpatient • Preschool age – usually viral • Amoxicillin is 1st line for immunized children • Macrolides for school age and adolescents with findings consistent with atypical pathogens • Influenza antiviral therapy – mod to severe CAP and findings consistent with influenza

PNEUMONIA - TREATMENT PNEUMONIA - TREATMENT

• Inpatient • Aspiration Pneumonia • Ampicillin – for immunized infants and children • Augmentin • 3rd generation cephalosporin • Clindamycin • not fully immunized or area with high level of PCN resistance • If life threatening infections or empyema • Macrolide – added if suspicion of atypical organism • Vancomycin/Clindamycin – used in addition to B-lactam if findings consistent with S. aureus.

PNEUMONIA – COMPLICATIONS

• Pulmonary • Metastatic • Pleural effusion/empyema • Meningitis • PTX • CNS abscess • Lung Abscess • Pericarditis • Bronchopleural fistula • Endocarditis • Necrotizing pneumonia • Osteomyelitis • Acute Respiratory Failure • Septic Arthritis • Systemic • SIRS/Sepsis • Hemolytic Uremic Syndrome

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PNEUMONIA - TREATMENT PNEUMONIA - PREVENTION

• When to discharge • Immunize • Fever • S. pneumonia • Activity • Haemophilus influenza type b • Appetite • Pertussis • Oxygenation • All infants 6 months and great and all children and • Mental status adolescents should get the flu vaccine annually • Tolerate medications • Caregivers with infants <6 months old should get the flu and pertussis vaccine

RSV

• A leading cause of hospitalization among infants • Estimated 100,000 admissions annually in the US • <24 months old 5.2/1000 • 1 month – 2 months 25.9/1000 • Premature infants (<30 weeks) 18.7/1000 BRONCHIOLITIS

• Study sponsored by CDC – over 5 years

RSV BRONCHIOLITIS

• By Age 1 - half of all children have been infected • Signs and Symptoms with RSV • Rhinitis and cough (URI)à tachypnea, wheezing, rales, • By Age 2 virtually all children have been infected accessory muscle use, nasal flaring • Re-infection common • Viral Lower Respiratory tract Infection • RSV • Human rhinovirus • Human Metapneumovirus • Influenza • Adenovirus • Coronovirus • Parainfluenza virus

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BRONCHIOLITIS GUIDELINES

• Updated in 2014 • Apply to children 1-23 months

• Diagnosis • Treatment • Prevention

BRONCHIOLITIS - DIAGNOSIS

• 1a. Clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical examination • 1b. Clinicians should assess risk factors for severe disease when making decisions regarding evaluation and management of children with bronchiolitis • <12 weeks of age • History of prematurity • Underlying cardiopulmonary disease • Immunodeficiency • 1c. When clinicians diagnose bronchiolitis on the basis of history and physical examination, radiographic or laboratory studies should NOT be obtained routinely.

BRONCHIOLITIS - TREATMENT BRONCHIOLITIS - TREATMENT

• 2. Clinicians should NOT administer albuterol to • 5. Clinicians should not administer systemic infants and children with a diagnosis of bronchiolitis corticosteroids to infants with a diagnosis of • 3. Clinicians should NOT administer epinephrine to bronchiolitis in any setting infants and children with a diagnosis of bronchiolitis • 6a. Clinicians may choose not to administer • 4a. Nebulized hypertonic saline should not be supplemental oxygen if the oxyhemoglobin administered to infants with a diagnosis of saturation exceeds 90% in infants and children with bronchiolitis in the Emergency Department a diagnosis of bronchiolitis • 4b. Clinicians may administer nebulized hypertonic • 6b. Clinicians may choose not to use continuous saline to infants and children hospitalized for pulse oximetry for infants and children with a bronchiolitis (weak Recommendation) diagnosis of bronchiolitis

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BRONCHIOLITIS - TREATMENT BRONCHIOLITIS - PREVENTION

• 7. Clinicians should not use physiotherapy for infants • 10a. Clinicians should not administer palivizumab to and children with a diagnosis of bronchiolitis otherwise healthy infants with a gestational age of • 8. Clinicians should not administer antibacterial 29 weeks, 0 days or greater medications to infants and children with a diagnosis • 10b. Clinicians should administer palivizumab during of bronchiolitis unless there is a concomitant the first year of life to infants with hemodynamic bacterial infection, or strong suspicion of one significant heart dz or CLD or prematurity defined as • 9. Clinicians should administer nasogastric or IV preterm infants <32 weeks 0 days gestation who fluids for infants with a diagnosis of bronchiolitis who require >21% oxygen for at least the first 28 days. cannot maintain hydration orally. • 10c. Clinicians should administer a max of 5 monthly doses (15mg/kg/dose) of palivizamab in the first year of life

BRONCHIOLITIS - PREVENTION BRONCHIOLITIS - PREVENTION

• 11a. All people should disinfect hands before and • 12a. Clinicians should inquire about the exposure of the after direct contact with patients, after contact infant or child to tobacco smoke when assessing infants and children for bronchiolitis. with inanimate objects in the direct vicinity of the • 12b. Clinicians should counsel caregivers about exposing patient, and after removing gloves. the infant or child to environmental tobacco smoke and • 11b. All people should use alcohol-based rubs for smoking cessation when assessing a child for hand decontamination when caring for children bronchiolitis. with bronchiolitis. When alcohol-based rubs are not • 13. Clinicians should encourage exclusive breast feeding available individuals should wash their hands with for at least 6 months to decrease the morbidity of respiratory infections soap and water. • 14. Clinicians and nurses should educate personnel and family members on evidence-based diagnosis, treatment, and prevention of bronchiolitis.

RSV AND ASTHMA ASSOCIATION

• IS MY KID GOING TO GET ASTHMA????

INFLUENZA

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INFLUENZA INFLUENZA

• History • Fever – 95 percent (50 percent had fever >39ºC) • Clinical Features • Cough – 77 percent • Physical Exam • Rhinitis – 78 percent • Diagnosis • Headache – 26 percent (among children 3 to 13 • Who to test? years of age) • Who to treat? • Myalgia – 7 percent (among children 3 to 13 years • Treatment of age) • Vaccine

INFLUENZA – WHO TO TEST INFLUENZA – WHO TO TREAT

• Children with clinical suspicion of influenza who are • Among individuals without risk factors for severe or complicated influenza, treatment of influenza with antiviral at high risk for complications, including children therapy shortens the duration of illness by approximately one younger than two years of age day if initiated within 48 hours of illness onset. • Antiviral treatment of high-risk patients has not been shown to • Hospitalized children with acute febrile respiratory reduce the duration of illness, but may decrease the risk of illness (even if symptoms develop during complications or need for hospitalization) • In accord with the Centers for Disease Control and Prevention hospitalization) and the American Academy of Pediatrics, we recommend • Hospitalized children with severe respiratory illness, antiviral therapy for • Children hospitalized with confirmed or suspected influenza including community-acquired pneumonia • Children with an influenza-like illness who are at increased risk of severe or complicated influenza) • Hospitalized children with possible neurologic • Otherwise-healthy children with influenza infection for whom a decrease in duration of clinical symptoms is felt to be warranted by his complications of influenza (eg, meningitis, or her provider encephalopathy)

INFLUENZA - PROPHYLAXIS

• Pre-exposure • Children at high risk for severe or complicated influenza • for whom influenza vaccine is contraindicated • during the two weeks after influenza immunization • Family members or healthcare providers who are unimmunized and are likely to have ongoing, close exposure to children younger than 24 months and unimmunized children who are at high risk for severe or complicated influenza • Unimmunized staff and children (to control influenza outbreaks in a closed institutional setting with pediatric residents at high risk for severe or complicated influenza) • High-risk children who may not respond to influenza vaccine, including those who are immunocompromised (as a supplement to influenza immunization) • Children at high risk and their family members/close contacts and healthcare providers when circulating strains of influenza virus are not matched with seasonal influenza vaccine strains

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INFLUENZA - PROPHYLAXIS INFLUENZA - COMPLICATIONS

• Post-exposure prophylaxis • Pneumonia • May be warranted for children who have had close • Myositis contact with a confirmed or suspected case of influenza during the infectious period • CNS • and who are at high risk for complications of influenza • Started within 48 hours of the most recent exposure

INFLUENZA - VACCINE INFLUENZA - VACCINE

• Who to Vaccinate • Who gets - Inactivated Influenza Vaccine (IIV) • All children 6 months of age or older • 6-23 months • Pregnant adolescents • Any child with chronic respiratory issues • Asthma • Any caregivers who will have close contact with children • Age 2-4 and any history of recurrent wheezing in previous 12 during the flu season months • All healthcare providers • Hematologic issues • Hepatic, Renal, and Neurologic Issues • Metabolic – including Diabetes Mellitus • Cardiovascular Disease as well as CHD • Residents of Long term care facilities • Immunosuppressed or contact with other who are immunosuppressed • Chronic ASA therapy

INFLUENZA - VACCINE INFLUENZA - VACCINE

• Who gets 2 doses??? • Contraindications • Age 6 month to 8 years old • Can be administered at the same time as other vaccine – • If they have NOT received at least 2 previous doses of must be at a different location trivalent or quadravalent prior to July 1, 2015 • Hx of severe allergic reaction to influenza vaccine • Sensitivity to thimerosal or gelatin– avoid these preparations • Special Populations • Moderate to Severe acute febrile illness should wait until • Immunosuppressed symptoms have resolved • Egg Allergy??? - NO • Steroids

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PERTUSSIS

• Epidemiology and Transmission • Spread by respiratory droplets, risk of transmission greatest during catarrhal stage • Clinical Features • Typical vs Atypical • Diagnosis PERTUSSIS • Treatment • Patient • Close contacts

PERTUSSIS – CLINICAL FEATURES

• Classic Pertussis • Catarrhal stage (1-2 weeks) • Paroxysmal stage (2-8 weeks) • 1-2 weeks: cough increases in frequency • 2-3 weeks: same intensity • 3 weeks on: gradually decrease in frequency • Convalescent Stage • Atypical – in immunized infants • Shorter/absent catarrhal phase • Paroxysmal: gagging, gasping, eye bulging, bradycardia,

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PERTUSSIS - DIAGNOSIS

• Think Pertussis over other URI • Paroxysmal cough • Post-tussive vomiting • Longer duration of symptoms • Absence of fever • Decreased incidence of congestion • Cyanoisis

PERTUSSIS - DIAGNOSIS

• Do NOT wait for lab confirmation • More difficult to grow after the paroxysmal stage and after abx started • Culture, PCR and serology – only culture and PCR are recognized

PERTUSSIS - COMPLICATIONS PERTUSSIS - TREATMENT

• Apnea • Supportive Care • Increased fluid needs • Seizures (1-2%) • Avoid cough triggers

• Pneumonia (18%) • Antimicrobial Therapy • Lab confirmation and <3 weeks of cough if >1 y.o. within 6 weeks of cough • Renal failure is <1 y.o. • Hypotension/Shock • Infants and children with a clinical dx (no lab confirmation needed) • Macrolide abx • Subdural hematoma • Who gets admitted • Rib fractures • Respiratory Distress • Leukocytosis (up to 60K) • Pneumonia • Inability to feed • Mortality rate is about 1% • Cyanosis/Apnea • Seizures • <4 months old and WBC >30K

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PERTUSSIS - PREVENTION

• Prophylaxis • Within 21 days of cough onset of index patient • Close contacts • Same household • Face to face exposure (<3 feet) • Direct contact with secretions • Sharing confined space with patient for >1 hour • High Risk • Infants <1 y.o. • Pregnant women • Immunodeficient patients • Underlying conditions (CLD, CF) • Persons who have close contact with infant

• VACCINATE

REFERENCES

• Hall, Caroline Breese, et al. “Respiratory Syncytial Virus-Associated Hospitalizations Among Children Less Than 24 Months.” Pediatrics. 2013;132;e341. • Cornfield, David N. “Bronchiolitis:Doing Less and Still Getting Better.” Pediatrics. 2014;133;e213 • Quinonez, Ricardo A. and Alan R Schroeder. “Safely Doing Less and the New AAP Bronchiolitis Guidelines.” Pediatrics. 2015;135;793. • Ralston, Shawn L, et al. “Clinical Practice Guidelines: The Diagnosis, Management, and Prevention of Bronchiolitis.” Pediatrics. 2014;134;e1474 • Yeah, Sylvia and ChrisAnna M Milk. “Bordetalla pertussins infection in infants and children: Clinical features and diagnosis” UpToDate • 2015;July 23. • Yeh, Sylvia. “Bordetella pertussis infection in infants and children: Treatment and Prevention” UpToDate 2015:Sept, 14. • Bradley, John S. “The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Disease Society and the Infectiou s Disease Socity of America.” Clinical Infectious Diseases. 2011;Aug;30. • Neuman, Mark I. “Prediction of Pneumonia in a Pediatric Emergency Department.” Pediatrics. 2011;128;246.

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