Transcript Diapositiva 1 - New Jersey Academy of Family Physicians

Bark, Cough, Wheeze
Kelly Ussery-Kronhaus, MD, FAAFP
Overview
• Respiratory
disease:
• 10% of pediatric
emergency
department
visits
• 20% of hospital
admissions
• 3-5% of deaths
in children
Separating upper from lower respiratory tract at the
epiglottis
Upper Airway Obstruction
• Pediatric airways are intrinsically smallfurther narrowing or collapse can have a
profound effect on airflow
• Etiologies of the edema leading to airway
collapse include:
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Mechanical (i.e. Foreign body aspiration)
Infectious (i.e. Epiglottitis, Pertussis)
Traumatic
A Clinical Vignette
A mother brings her 14 month old son, Jimmy,
into the urgent care clinic with complaints of
choking and gagging after eating potato
chips15-20 minutes ago at his grandmother's
house. His mother is unsure if he had eaten
anything else with the potato chips and does not
think the child turned blue during the choking
and gagging episode. He returned to his normal
activity shortly after the episode occurred, but
since then, he has had a few intermittent
coughing spells. The patient has two older
siblings who are still at the grandmother's
house.
Physical Exam
• Vital Signs:
• T 37.2, P 103, R 28, BP 98/55, O2
saturation 96% on RA
• Height/weight/head circumference are all
25-50%ile
Physical Exam
• Physical Exam:
• General: NAD
• Chest: Occasional low pitched monophonic
expiratory wheeze best heard over the
sternal notch
Diagnosis
Diagnosis 2
Foreign Body Aspiration
• Three Phases of foreign body aspiration:
• Phase 1:
• The patient will usually experience:
• choking, gagging, coughing, wheezing, and/or stridor
• temporary cyanotic episode is possible, usually perioral
• Phase 2:
• Asymptomatic period
• can last from minutes to months The duration of this
period depends on the
• Phase 3:
• The renewed symptomatic period.
• Airway inflammation or infection from the foreign body will
cause:
• Cough, wheezing, fever, sputum production, and
occasionally, hemoptysis
Management
• If the patient is stable (i.e., forcefully coughing, well oxygenated):
• Removal of the foreign body via bronchoscopy or laryngoscopy
• If there is complete airway obstruction:
• Percutaneous (needle) cricothyrotomy
A rapidly progressive
cellulitis of the of the
epiglottis and
surrounding structures
EPIGLOTTITIS
Epiglottitis
• Clinical presentation:
• Symptoms:
• Sore throat
• high fever
• dysphagia
• Respiratory distress progresses in
<12hrs
Epiglottitis
• Infectious Etiologies:
• H. influenzae B
• Non-typeable H.
influenzae
• Haemophilus
parainfluenzae
• S. aureus
• S. pneumoniae
Epiglottitis:
Management
Hemophilus Influenza B (Hib)
• 2 vaccines available
• 1 is 3-dose series (PedvaxHIB®)
• 1 is 4-dose series (ActHIB®)
• Vaccines are interchangeable
• If changed at 2 or 4 months of age, need a 6month dose of either vaccine
• Either vaccine may be given for the
12-month booster dose
Hemophilus Influenza B (Hib)
• Cannot give any form of Hib to infants
less than 6 weeks old
• Have decreased immune response to
polysaccharide capsule (PRP) of Hib
• May also prevent future ability to develop
antibodies
PedvaxHIB®
•
•
Hemophilus influenza type b vaccine
Antigen conjugated to Meningococcal
Group B outer membrane protein
(PRP-OMP)
•
2-dose primary series plus booster
•
2, 4 months and 12-15 month booster
•
Also comes in a combination vaccine with
Hepatitis B (Comvax®)
Act-HIB®
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•
•
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Hemophilus influenza type b vaccine
Conjugated to tetanus toxoid (PRP-T)
3-dose primary series plus booster
2, 4, 6 months and booster at 12-15
months
• Also comes in 2 combination vaccines
• With DTaP, and IPV (Pentacel®) Primary series
• With DTaP (TriHibIt®) Booster dose only
Prevnar® (PCV-7)
•
Pneumococcal conjugate 7 valent vaccine
•
2, 4, 6 and 12 months
•
Recommended for all children 2-23 months
•
Give if 24-59 months old with risk factors
•
Not for children >5 years old
•
Replaced by PCV-13 Spring 2010
PCV-7 PCV-13
(Prevnar™13)
•
ACIP voted 2/24/10 to replace PCV-7
•
Transition guidelines published
•
Protects against 13 instead of 7 strains
•
•
Expanded vaccination for high-risk
groups to 72 months
Same dosing interval as PCV-7 for never
vaccinated children
PCV-13
• High risk children include
• Immunocompetent children with
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Cyanotic congenital heart defects
Chronic lung disease
Asthma needing oral steroid treatment
Diabetes
CSF leaks
Cochlear implants
Asplenia (congenital or acquired)
Sickle cell and other hemoglobinopathies
PCV-13
• High risk children include
• Immunocompromised children
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HIV
Chronic renal failure
Nephrotic syndrome
Lymphoma and leukemia
Chemotherapy
Organ transplant
Congenital immunodeficiencies
New for PCV-13
• Single dose for children 6-18 years old at
increased risk for invasive pneumococcal
disease
• Give regardless of previous PCV-7 or
PPSV-23 vaccination
• Includes:
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Sickle cell disease
HIV (or other immunocompromised state)
Cochlear implant
CSF leaks
• croup
Croup management
PERTUSSIS
Pertussis
• 3 phases of illness (post-incubation):
• Catarrhal
• Paroxysmal
• Convalescent
• Complications:
• Pneumothorax, pneumomediastinum &
air in soft tissues
Pertussis
Clinical presentation
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•
Symptoms:
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Mild to severe
paroxysmal cough with
dyspnea
Signs:
•
Paroxysms of cough
•
Inspiratory whoop
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Apnea & cyanosis
(infants)
Diagnosis
•
•
PCR or culture
DTaP
•
Capital letter denotes full dose vaccine
•
Small “a” for acellular
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Compared to Td or Tdap
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Small letter denotes half dose vaccine
for booster effect
Diphtheria and Pertussis vaccines only
given as combination with Tetanus
DTaP
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Diphtheria
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Tetanus
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Acellular pertussis
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Primary series
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2, 4, 6 months
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12-18 months (at least 6 months from the 3rd dose)
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4 years
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12-14 years Tdap
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Then Td boosters every 10 years
DTaP
Contraindications
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Severe allergic reaction (e.g., anaphylaxis) after a previous vaccine dose or
to a vaccine component
Encephalopathy (e.g., coma, decreased level of consciousness; prolonged
seizures)
•
not attributable to another identifiable cause
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within 7 days of administration of previous dose of DTP or DTaP
Progressive neurologic disorder
•
including infantile spasms
•
uncontrolled epilepsy
•
progressive encephalopathy
Defer DTaP until neurologic status clarified and stabilized
DTaP
Precautions
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Temperature of >104°F (>40.5°C)
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Collapse or shock-like state
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lasting >3 hours within 48 hours of a dose of DTP/DTaP
Guillain-Barre syndrome (GBS)
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<3 days after a previous dose of DTP/DTaP
Persistent, inconsolable crying
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Occurs <48 hours after a previous dose of DTP/DTaP
Seizure
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For <48 hours after a previous dose of DTP or DTaP
<6 weeks after dose of tetanus toxoid-containing vaccine
Moderate or severe acute illness with or without fever
Safe Situations to Administer DTaP
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Temperature of <105°F (<40.5°C) after dose
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Fussiness after dose
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Mild drowsiness after dose
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Family history of seizures
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Family history of sudden infant death syndrome
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Family history of an adverse event after vaccine
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Stable neurologic conditions
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cerebral palsy
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well-controlled seizure disorder
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developmental delay
Management:
Pertussis
• Monitoring
• Cardiorespiratory monitoring
• Continuous pulse oximetry
• Apnea monitor
• Treatment:
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PRN oxygen
Stimulation/ suctioning
Avoidance of large volume feedings
Macrolides x 14 days
Clinical Vignette
•
Amy, a 10-week-old girl presents to her
physician's office in January because her mother
feels her breathing is labored. She was born fullterm; pregnancy, labor, and delivery were
uncomplicated. The baby’s mother smoked
during pregnancy and continues to do so. The
family history is negative for asthma or allergy.
She developed rhinitis and a tactile fever 3 days
prior to presentation. Over the next few days she
developed increasing cough, increased work of
breathing, and decreased PO intake.
Clinical Vignette cont.
Vital Signs:
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T 100.4°F, R42, O2 saturation 93% on
RA, BP 85/55, P 180
Physical Exam:
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General: Mild distress 2° respiratory
distress, + wet cough
Chest: Mild intercostal retractions,
scattered crackles bilaterally, and
expiratory wheezes bilaterally
Diagnosis
• Diagnosis is often
clinical during the RSV
season
• Diagnostic testing can
be done by:
• Immunofluorescence
• ELISA
Management
• Supportive care
•
Consider hospitalization:
• <12 weeks
• History of prematurity
• Underlying
cardiopulmonary disease
• Immunodeficiency
• Supplemental oxygen therapy/
Fluid Support
• A trial of bronchodilators
• Corticosteroids and antibiotics
not routinely recommended
Clinical Vignette Cont.
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Due to her young age Amy is hospitalized
and observed over the next 24 hours.
With supplemental oxygen therapy and a
trial of bronchodialators the infant
demonstrates improvement.
She is sent home and her mother is
advised to refrain from smoking around
her child.
Asthma
• Most frequent respiratory
diagnosis for children
admitted to hospitals
• Causes 5000 deaths
annually in the United
States
• It is a complex syndrome
consisting of inflammation
which leads to:
bronchospasm
airway
• hyperirritability
Asthma Triggers
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Respiratory Infections
Allergens
Airway Irritants
Exercise
Medications (NSAIDS and Beta Blockers)
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MAJOR RISK FACTORS
(at least one must be present)
• parental history of asthma
• atopic dermatitis
• sensitization to aeroallergens
45
MINOR RISK FACTORS
(2 required)
• sensitization to foods
• more than 4% eosinophilia
• wheezing apart from colds
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Aeroallergen
• Indoor:
• Dust mite
• Cockroach
• Animal dander
• Mold
– Immunotherapy for children with documented sensitivities and
mild or moderate persistent asthma (LOE B for dust mite, animal
dander, and pollen)
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Exercise Induced Asthma
• Can be the only manifestation of asthma
• Symptoms: cough, shortness of breath
and rarely wheezing
» Onset: 5-10 min after stopping exercise
» Resolution: 20-30 min later
48
Classifying Severity an Initiating
Treatment: Children 0-4 years
Severity
category
Days and
nights with
symptoms
Interference
with normal
activity
exacerbation
Preferred
Treatment
Severe persistent
Throughout (D)
>1 night/wk (N)
Extremely limited
See below
Step 3:
Med dose ICS
and consider short
course OCS
Moderate
persistent
Daily (D)
3-4 nights/month
Some limitation
See below
Step 3: med dose
ICS and consider
short course OCS
Mild persistent
3-6 D/wk
1-2 N/month
Minor limitation
2 or more/6m or
>= episodes of
wheezing/yr with
risk factor
Step 2: low dose
ICS
Intermittent
<=2 D/wk
0 night/month
None
0-1/y
Step 1: SABA prn
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Classifying Severity and Initiating Treatment:
children 5-11
Severity
category
Days and
nights with
symptoms
Interference
with normal
activities
Pulmonary
function
Exacerbations
Preferred
treatment
Severe persistent
Throughout (D)
Often (N)
Extremely limited
FEV1<60%
FEV1/FVC<75%
2 or more/y
Step 4: medium
dose ICS+LABA
and consider short
–course OCS
Step 3: Medium
dose ICS and
consider short
course OCS
Moderate
persistent
Daily (D)
>1 N/wk
Some limitations
FEV1:60-80%
FEV1/FVC: 7580%
2 or more/y
Step 3: medium
dose ICS and
consider short
course OCS
Mild persistent
3-6 D/Wk
3-4 N/Month
Minor limitation
FEV1>80%
FEV1/FVC>80%
2 or more/y
Step 2: low dose
ICS
Intermittent
<=2 D/wk
<= 2 N/month
None
FEV1>80%
FEV1/FVC>85%
0-1/y
Step 1: SABA prn
50
Classifying Severity and Initiating Treatment:
youth 12 years of age and older
Severity
category
Days and
nights with
symptoms
Interference
with normal
activities
Pulmonary
function
Exacerbations
Preferred
treatment
Severe persistent
Throughout (D)
Often (N) 7x/wk
Extremely limited
FEV1<60%
FEV1/FVC:
Reduced>5%
2 or more/y
Step 5: high dose ICS
+LABA and consider
short course OCS
Step 4: medium dose
ICS+LABA and
consider short –course
OCS
Moderate persistent
Daily (D)
>2-6 N/wk
Some limitations
FEV1:60-80%
FEV1/FVC:
Reduced >5%
2 or more/y
Step 3: low dose ICS
+LABA
Or
medium dose ICS and
consider short course
OCS
Mild persistent
3-6 D/Wk
3-4 N/Month
Minor limitation
FEV1>80%
FEV1/FVC:normal
2 or more/y
Step 2: low dose ICS
Intermittent
<=2 D/wk
<= 2 N/month
None
FEV1>80%
FEV1/FVC: normal
0-1/y
Step 1: SABA prn
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Comorbid conditions
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Infection
Obesity
Depression in child or parent
Gastroesophageal reflux
Allergies
OSA
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Summary
• Initial management of
asthma includes:
1) assignment of severity
category
2) identification of asthma
“triggers”
3) development of a
treatment plan based on
severity
Inhaled corticosteroids are
the medication choice for
treatment of persistent
(LOE A)
Environmental control is
an important component
of asthma management
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Patient education
• Including how to use a written asthma
action plan is critical to the management of
asthma (LOE A)
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