Transcript Peds Respiratory Emergencies

Peds Respiratory Emergencies
Adam Davidson
Adam Oster
May 7, 2009
Thank You’s
 Nicole Kirkpatrick
 Adam Oster
Outline
 Anatomy
 ABC’s
 Upper Airway Emergencies
 Lower Airway Emergencies
Anatomy
 Prominent Occiput-can cause head flexion
 Usually
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no need to place pillow/towel
 Head extension should put in sniffing position
Tongue is disproportionally large compared to mouth
Larynx is higher in neck (C3-C4 vs C4-C5 in adults)
Anterior larynx
Large/Floppy epiglottis (choice of laryngoscope
blade?)
Narrowest portion is at cricoid
Resuscitation
 Airway
 Look: alert?, protecting?, cyanotic? Foreign
body?
 Listen: stidor, gurgling, crying, talking
 Manage: sit pt up, oxygen, OPA/NPA, finger
sweep, jaw thrust, prepare to intubate
Resuscitation
 Breathing
 Look: rate, indrawing, accessory muscles, nasal
flare, cyanosis
 Listen: stridor, wheeze, crackles, AE bilat, quiet,
able to speak in sentences
 Manage: O2, meds, bag mask, intubation
 Meds: Ventolin, Atrovent, Mg, Epi, Steroids, Abx,
Lasix
 Nasal flaring and chest retractions more sensitive
than tachypnea for resp distress
Resuscitation
 Circulation
 Look: pale, lethargic, diaphoretic, mottled, LOC
 Listen: heart sounds, murmurs
 Feel: pulses, pulsus paradoxus, cap refill
 Manage: fluid if no signs CHF, PALS
 Adjuncts: CXR, ABG/Cap Gas, ECG, Bloodwork,
Soft-tissue films
Cap Gas versus ABG’s
 Excellent approximations of pH and CO2
 Are accurate for detecting hypoxemia but correlation
falls off as PaO2 values rise
 Errors occur with false +ves, therefore good screen
 More blood flow to area, more accurate the reading
 Make sure to warm area to increase vasodilation
Resuscitation
 RSI
 Pre-Oxygenation
 Pre-treatment:
 Atropine: 0.02mg/kg (Minimum Dose?, Why?)
 Lidocaine: 1.5 mg/kg
 Induction:
 Ketamine: 1.5-2mg/kg
 Paralysis:
 Succinycholine: 2mg/kg
Physical Exam
 Stridor
 Hallmark of URT obstruction
 Inspiratory: usually supraglottic, associated with
collapse due to negative pressure
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Associated with: drooling, hot-potato voice
Eg: abscess, croup, epiglottitis
 Biphasic: usually fixed obstruction at glottis
 Eg: laryngeal webs, vocal cord paralysis
 Expiratory: usually sub-glottic, associated with
positive pressure of expiration
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Eg: Tracheitis, foreign body
Physical Exam
 Grunting
 LRT pathology
 Forced expiration creating auto-PEEP
 Presence usually represents significant distress
 Wheeze
 LRT pathology
 Asthma, Bronchiolitis, Cardiac, Pneumonia
Location
 Upper Airway
 Lower Airways
 Cardiac
 CHF: congenital, myocarditis, cardiomyopathy
 PE
 Tamponade
 Neurologic
 SAH, Shaken Baby, meningitis, opiates, anxiety
 Metabolic
 DKA
 CO poisoning, Methemoglobinemia, Hydrogen Sulphide
THE UPPER AIRWAY
Pediatric Respiratory Emergencies
Partial Differential
 Foreign body
 Epiglottitis
 Croup
 Tonsillitis
 Abscess (retro/parapharyngeal, peritonsillar)
 Anaphylaxis
 Angioedema
 Burns
 Caustic Ingestion
 Congenital Abnormality
 Bacterial Tracheitis
13 year old female with fever and sore throat
Recurrent “Strep throat”
Can barely talk, hasn’t been able to eat or drink for 24hrs
Peritonsillar Abscess (Quinsy)
 Risk Factors: chronic tonsillitis, mono, CLL, dental
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infection, older age
Odynophagia, dysphagia, drooling, hot-potato voice,
rancid breath, fever, malaise, dehydration
Uvular deviation and trismus most specific for
abscess
Abscess vs Cellulitis: aspiration of pus
May need sedation but needle less painful than I+D
Cut plastic needle cover to form guard
No cases in literature of carotid puncture
Peritonsillar Abscess
 Needle aspiration shown to be as efficacious as I+D
 Can be performed in ED
 Admit: septic, dehydrated and not able to drink,
unreliable follow-up, unable to aspirate
 If able to tolerate PO fluids, can give dose of IV Abx
and f/u with HPTP
 Abx: Clinda (usually 1st choice), Ancef/Flagyl
 Steroids: very few studies exist with conflicting data
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Practice seems to vary between ENT surgeons
No evidence of harm
Steroids For Phayngeal Swelling
 Some ENT surgeons swear by giving steroids to reduce
edema/swelling in the pharynx
 Common practice for mono and peritonsillar abscess
 Cochrane Review 2009 for steroids with mono
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Symptomatic Relief for 12 hours only
No difference in complete resolution or length of disease
 No evidence for peritsonsillar abscess, retropharyngeal
abscess
 Consider for patients with acute airway obstruction or
those who can’t tolerate PO fluids (Dex 10mg IV)
Dickens, KP, et al. Should you use steroids to treat infectious mononucleosis? The Journal of Family Practice, 2008
Retropharyngeal Abscess
 More common in young children (Age: 6m-3yr)
 Post URTI or secondary to FB trauma (toothbrush,
popsicle stick, etc)
 Toxic, febrile, drooling, stridor, dysphagia,
opisthotonos (can look like meningitis)
 Px: bulgling posterior pharyngeal wall
 Soft tissue films: large retropharyngeal space (>1/2
width of vertebral body), retropharyngeal air
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False +ve: expiration film, neck flexion
 Treatment: IV Clinda, IV Dex, generally admitted to
PICU for monitoring with ENT consult
Croup (Laryngotracheobronchitis)
 Most common cause of stridor for ages 6m-3yr
 Causes: always viral
 Parainfluenza (MCC), Influenza, Adenovirus, RSV
 Usually benign and self-limited
 severe disease more common in males
 Peaks in fall/winter
 URTI with 3-4d hx of worsening cough
 Barky cough, stridor, sx usually worse at night
 Stridor worse with anxiety (ie: in ED)
 Usually non-toxic with low-grade fever
 Hypoxia is a rare and late sign
Clinical Croup Score
 Insp Breath Sounds:
 Normal (o), Harsh (1), Delayed (2)
 Stridor:
 None (0), Inspiratory (1), Expiratory (2)
 Cough:
 None (0), Hoarse Cry (1), Bark (2)
 Retractions/Flaring:
 None (0), Suprasternal (1), Sub/intercostal (2)
 Cyanosis:
 None (0), Room Air (1), 40% O2 (2)
Mild: <4
Mod: 4-6
Severe: >6
Croup Treatment
 Intubation: usually can be avoided with aggressive Tx
 (if necessary, use ETT 1 size smaller than expected)
 Steroids: Dex 0.6mg/kg (max 10-20mg?) PO/IM/IV
 Good evidence for moderate, severe croup
 Decr admission, intubation, return to ED, croup scores
 NEJM 2004 showed benefit in mild croup as well
 No side-effects, One dose lasts 48 hrs
 Nebulized Epi:
 1:1000 Epi (L isomer only) just as good as racemic
 Nebulize 5ml q2-3hr for maximum of 3 doses (back to back if
impending intubation)
 Good evidence for severe croup
 Contraindications: mechanical cardiac outflow obstructin (AS, ToF)
 Complications: MI, V-tach
Steroids and Croup
 Dex shown to be superior to Prednisolone
 Single dose of 0.15mg/kg equivalent to 0.3 and 0.6
Croup Disposition
 Mild
 Dex PO and D/C home
 Moderate
 Dex PO and observe for 3-4hrs before D/C
 Severe
 Dex (IV/IM) and Epi, observe for 4-6hrs before D/C
 Admission
 Co-morbidities, social situation, complicated airway or
previous difficult intubation, dehydration
 Discharge Instructions
 Cool air, popsicles, humidity?, F/U with GP in 24-48hrs
Bacterial Tracheitis
 Sub-glottic bacterial infection
 Can occur at any age, males = females, no seasonal
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preference
Polymicrobial bacterial superinfection following
Croup (primary infection less common)
Staph (50%), Strep, H flu, Moraxella
Bacterial invasion with copious mucous secretions
Airway obstruction secondary to mucous
Bacterial Tracheitis
 Patient with barky cough and low-grade fever
suddenly develops high fever and toxic appearance
 More respiratory distress than Croup
 Can appear like Epiglottitis with fever, drooling, resp
distress
 Consider if:
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Toxic looking Croup
Croup lasting >4 days
Croup not responding to treatment
Bacterial Tracheitis
Diagnosis
 Soft Tissue Films: “shaggy” irregular tracheal wall
with intraluminal membrane, steeple sign
 Dx: laryngobronchoscopy shows normal epiglottis w/
+++ secretions
 Complications
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Airway obstruction, ETT plugging (common, consider Trach)
Sepsis, DIC, Toxic Shock from Staph
Bacterial Tracheitis Management
 Airway management best done in OR with
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Anesthesia consult
IV Abx: Cefotaxime/Clindamycin
ICU Admission post OR
Daily bronchoscopy to remove secretions
Consider Trach if persistant ETT plugging
No benefit to steroids or nebulized epi
THE LOWER AIRWAYS
Pediatric Respiratory Emergencies
Case 1
2M male
3 day history of URTI associated with fever (38.5)
Onset of difficulty feeding, increased WOB today
Vitals - HR 160 RR 65 SpO2 90% on R/A T 37.9
TT, indrawing, nasal flaring, diffuse crackles and
wheezes
Differential diagnosis of Wheeze
 Infection (Bronchiolitis, pneumonia)
 Asthma
 Cystic Fibrosis
 CHF
 Foreign body
 Anaphylaxis
 Croup
 Epiglottis
 Vocal cord dysfunction
 GERD
 Bronchopulmonary dysplasia
You think he has bronchiolitis
 What do you tell his parents about his illness and its
natural history?
Bronchiolitis
 Viral infection
 RSV, influenza, parainfluenza, echovirus, rhinovirus,
adenovirus
 Mycoplasm, Chlamydia
 Children < 2 years, peak at 2 M
 October to May
 Contact/Droplet
 Peak at 3-5 d
 Resolves 2 weeks
Bronchiolitis
 Inflammation of terminal and respiratory
bronchioles
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Mucus plug + edema
Airway narrowing
Decrease compliance, increase resistance
Atelectasis and overdistention
Bronchiolitis
 Clinical presentation
 Wheeze, tachypnea, indrawing
 URT symptoms
 Fever
 Hypoxemia
 Apnea
What factors put children at increased risk of
severe bronchiolitis?
 History of
 Prematurity
 BPD
 CF
 Congenital heart disease
 Immunocompromised
Management
 You start oxygen and encourage feeding
 When patient not feeding well you give 20 mL/kg
bolus
 RT asks you if you want this child to be treated with
bronchodilators or steroids…
 What do you think?
Controversial
 Many trials done to examine use of
 Epinephrine
 ß-adrenergics
 Steroids
IV
 PO
 Inhaled
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Evidence for Epinephrine
 Epinephrine vs. placebo or salbutamol
 5/8 showed short term improvement in
clinical scores
 1/8 showed fewer hospitalization
 1/8 showed shorter duration of hospitalization
Evidence for Epinephrine
 Hartling et al, 2003
 Meta-analysis
 Epinephrine vs. bronchodilators or placebo
 RCT, infants<2 years, quantitative outcome
 14 studies, 7 inpatient, 6 outpatient, 1 unknown
 Outpatient results
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Epi better than placebo or other bronchodilators in short term (O2
saturation, RR, clinical score)
Evidence for Epinephrine
 Cochrane Systematic Review
 14 RCT (1966-2003)
 Inpatient and outpatient treatment
 Epinephrine vs. placebo - outpatient (3)
 Improvement at 60 minutes (1/3studies)
 No difference in admission or O2 saturation
 Epinephrine vs. Salbutamol - outpatient (4)
 O2 saturation, HR, RR improved at 60 minutes
 No difference in admission
Evidence for Bronchodilators
 13 RCT
 Bronchodilators vs. placebo or ipatropium
 1/13 showed decreased admission
 4/13 showed some clinical improvement
Evidence for Bronchodilators
 Cochrane Systematic Review
 22 RCT (1966-2005)
 Bronchodilators vs. placebo
 No difference in admission or duration of
hospitalization
 Minor improvement in oximetry and symptoms in
outpatient treatment
 Previous studies used larger doses of
epinephrine
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Effect may not be due to alpha affects, but higher
delivery of ß-agonist
 RCT comparing racemic epinephrine, racemic albuterol,
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normal saline in equivalent doses in mild/moderate
bronchiolitis
N = 65 (23-albuterol, 17 epi, 25 NS)
5mg of drug in 3 mL at 0 and 30 minutes
Clinical assessment pre and post
3 rd dose at 60 minutes if RDAI >8 or O2 saturation < 90%
R/A
Final assessment at either 60 or 90 minutes
 Required admission/home oxygen
 61% albuterol, 59% epinephrine, 64% NS
 No difference in admission rates
 No difference in O2 saturation, RR
 ß-agonist not useful in Rx bronchiolitis
 “ß-agonists should not be used routinely in management
of bronchiolitis” Level B
 “A carefully monitored trial of alpha adrenergic or ßadrenergic medications is an option…and continued only
if there is a documented positive clinical response using
objective means of evaluation” Level B
 “…it would be more appropriate that a bronchodilator
trial…use salbutamol rather than racemic epinephrine”
 What about steroids?
 Systematic review
 Oral, IV and inhaled steroids
 Oral
 6 RCT involving prednisone (1) prednisolone (2)
Dexamethasone (2) Prednisolone and albuterol vs.
Placebo and albuterol
 Various outcomes (hospitalization, clinical score, length
of stay, duration of ventilation)
 1 found decreased rate of admission, 1 found increased
rate of admission,1 found shorter duration of ventilation,
1 found improved clinical status
 Felt data was inconclusive
 IV
 2 RCT
 Dexamethasone to placebo
 No benefit
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Clinical score, admission, time to resolution, duration of oxygen
therapy
 Inhaled
 6 RCT
 Mostly used budesonide
 Worse wheeze/cough at 12 months in 1
 Increase readmission
 No benefit shown
Evidence for Steroids
 Cochrance Systematic Review
 13 RCT
 No difference
 RR
 O2 saturation
 Admission
 Length of stay
 Subsequent visits
 Readmission
 RCT
Comparing admission to hospital and RACS 4 hours
after dose of dexamethasone (1mg/kg) versus placebo
January 2004 - April 2006
N = 600 (305 dexamethasone, 295 placebo)
Admission
 39.7% in dex vs. 41% in placebo - no difference
RACS - sum of change in RDAI minus standardized score
for change in RR (negative value = good response)
 No difference
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“Corticosteroid medications should not be used
routinely in the management of bronchiolitis”
Level B
Palivizumab
 Humanized, mouse monoclonal anti-RSV
antibody
 Monthly X 5 months, 15 mg/kg IM
 Prevention of serious RSV lower respiratory
tract infection
Children < 2 years
 Chronic lung disease of prematurity
 Premature ≤ 32 weeks
 Hemodynamically significant cyanotic or acyanotic
congenital heart disease
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 Any novel treatments?
Hypertonic saline
 Mechanism incompletely understood
 Osmotic hydration
 Reduction of cross-linking
 Edema reduction
 RCT, multicentre comparing length of stay in
admitted patients receiving treatment with 3% HS
vs. NS
 N=93 (47 - HS, 49 - NS)
 Doses q 2h X3, q4h X5, q6h until D/C
 Any other treatments mixed with appropriate
solution
 Length of stay
 HS 2.6 days +/- 1.9 days
 NS 3.5 days +/- 2.9 days
 26% reduction in LOS
 P = 0.05
 RCT comparing epinephrine 1.5 mg in 4 mL NS
vs. epinephrine 1.5 mg in 4 mL of HS
 N = 53 (25 NS, 27 HS)
 Length of stay, change in clinical severity
 NS 4 +/- 1.9, HS 3 +/- 1.2, p < 0.05
Case 3
 6 yo M with PMH of asthma
 URTI X4 days, using blue puffer
 Increase WOB today
 HR 130, RR 35, 90% on R/A
 Indrawing, Audible wheeze
 Decreased breath sounds to R
 Wheeze
How do you want to treat this child?
Evidence for Anti-cholinergics
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NEJM 1998
RDBCT
Albuterol vs. albuterol+ IB x 2 dose
N=434 (2-18 years)
IB
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Decreased hospitalization (27 vs 36%, p = 0.05)
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Similar hospitalization rates in moderate exacerbation
Markedly different rates in severe exacerbations
Evidence for Anti-cholinergics
 32 studies, 16 pediatric
 10 studies - admission (1786 children)
 Lower admission rate
 NNT =13, 7 if only severe exacerbations included
 9 studies - spirometry
 1 or 2 doses had FEV1 difference of 12.4%
 >2 doses had FEV1 difference of 16.3%
Evidence for Anti-cholinergics
 Cochrane Systematic Review 2000
 13 trials
 Multiple doses decreased risk of admission by 25%
 Single doses improved lung function at 60 and 120
minutes, but no admission
 NNT= 12 to avoid 1 admission in kids with either
moderate or severe exacerbation
 NNT = 7 if severe exacerbations
Nebulizer vs. MDI/Spacer
 RDBCT
 N = 168 (2m to 24 months)
 Nebulizer vs. Spacer
 Primary outcome
Admission rates
 Results
 Controlled for difference in baseline
 Spacer group admitted less
 5% vs. 20% p=0.05
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Nebulizer vs. MDI/Spacer
 RDBCT
 N=90 (5 -17 years) baseline FEV1 50-79%
 Treatment groups
6-10 puffs
 2 puffs
 0.15mg/kg nebulized
 Primary outcome
 Improvement in % predicted FEV1
 Results
 No significant difference in % predicted FEV1 between groups
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Nebulizer or MDI/Spacer
 Cochrane Systematic Review 2006
 Beta agonist via wet nebulizer vs. spacer
 25 outpatient trials
 N = 2066 children, 614 adults
 MDI+spacer was equivalent to wet nebulizer wrt
hospital admission rates
 MDI+spacer in kids
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Decreased length of stay in ED
Continuous vs. Intermittent
 Cochrane Systematic Review 2003
 Continuous or near continuous (q 15 minutes or >4
treatments/h) vs. intermittent nebulization
 Continuous beneficial
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Decreased admission
Most pronounced if severe exacerbation
Evidence for use of steroids
 Cochrane Systematic Review 2001
 Benefit of treatment within 1 hour of ED
presentation
 12 trials
 N = 863
 Reduced admission rates, NNT = 8
 Most benefit
Not currently Rx with steroids
 Severe exacerbation
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 Oral steroids worked well for kids
Evidence for MgSO4
 5 trials
 IV MgSO4 at any dose vs. placebo in patients <
18 y treated with beta-agonists and steroids
 MgSO4 reduced hospitalization
 NNT=4 for avoiding hospitalization
Evidence for MgSO4
 Cochrane Systematic Review
 7 trials (5 adult, 2 pediatric)
 N= 665
 In severe subgroup
 Improved PEFR, FEV1, admission rates
 Improvements not seen if all patients included
Evidence for MgSO4
 Cochrane Systematic Review 2005
 Inhaled MgSO4
 6 trials
 N=296 (2 pediatric)
 Heterogenous studies therefore difficult to make
definitive conclusion
 MgSO4 with beta-agonists showed benefit
Pulmonary function
 Admission rates
 In severe exacerbations
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Evidence for IV Salbutamol
 Cochrane Systematic Review 2001
 IV salbutamol in addition to other Rx vs. placebo
 15 trials
 N=584
 No benefit
 Pulmonary function
 Arterial gases
 Vital signs
 AE
 Clinical success
Other treatments
 Heliox
 NIPPV
Case 3
 5 M Male
 Cough, fever, decreased energy and intake
 Tachypnea, increased wob
 SpO2 90% on R/A, RR 60
 Crackles in RLL
 CXR
 Consolidation in RLL
Epidemiology
 4% of kids/y in U.S.
 Decreases with increasing age
 < 2 years – 80% viral
 > 4 years – 40% viral
Clinical features
 Cough, fever, CP, tachypnea, grunting (infants),
increased wob (indrawing, seesaw)
 Typical presentation - bacterial
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Rapid onset
Fever, chills, chest pain, cough
 Atypical presentation – viral
 Gradual onset
 Malaise, h/a, cough, fever (low-grade)
 Significant overlap
Pneumonia bugs
Specific bugs
 B. pertussis
 3 stages
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Catarrhal phase
• Coryza, cough lasting 1-2 weeks
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Paroxysmal phase
• Coughing fits associated with gagging, cyanosis
• Whoop is uncommon in infants
• Lasts ~ 4 weeks
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Recovery
• Cough improves over months
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Treatment
Specific bugs
 S. aureus
 Rapid and severe
 C. trachomatis
 50% of exposed will get conjunctivitis
 5-20% pneumonia
 2-19 weeks
 Rarely febrile or systemically unwell
 Staccatto cough
CXR in ambulatory setting
 N = 522 (2M to 59M)
 Randomized to CXR or no CXR
 Primary outcome
 Results
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Median 7 days to recovery in both groups
CXR group
 More diagnosed with pneumonia
 60% vs. 52% treated with antibiotics
 More follow-up appts.
 No difference in consultation, admission, repeat CXR at 28 days
CXR
 Bacterial
 Lobar or segmental consolidation
 Viral and atypical bacterial
 Interstitial infiltrates
 Peribronchial thickening
 Atelectasis
 Significant overlap
 Not useful in determining etiological agent
CXR
 May want to avoid in mild acute LRTI
 Use if <5 and if fever >39 or toxic
Admission
 SpO2<90-93%
 Young age
 Toxic
 Immunocompromised
 RR>70 (infant), >50 (older children)
 Respiratory distress
 Apnea/grunting
 Not feeding or dehydrated
 Social concerns