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Program MCPS/MRCGP/CEFM CME ©

Course Paediatrics

Module Respiratory

Topic COMMON RESPIRATORY INFECTIONS

Credit Hours 1 CME credit hour

Total Educational hours 2 educational hours

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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Prof. Nasir Shah
MCPS, FCPS, MRCGP [INT], FRCGP [INT]

Dean Family Medicine Faculty, College of Physicians and

Surgeons Pakistan

Convener National Family Medicine Committee of

Pakistan

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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TOPICS ®
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1. Croup
2. Bronchiolitis
3. Reactive airway disease
4. Laryngomalacia
5. Childhood Pneumonia

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

CROUP: LARYNGO-TRACHEO-BRONCHITIS ®
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MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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CROUP | INCIDENCE & PRESENTATION ®
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• Common with many viral infections
• Occurrence in epidemics
• Usually in autumn and spring
• Frequency of attacks associated with viral URTI

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

CROUP | INCIDENCE & PRESENTATION ®

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• CLINICAL FEATURES
- Mild fever
- Runny nose
- Barking cough and
inspiratory stridor in (<4y)
• The cough
- Typically starts at night
- Exacerbates by crying

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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CROUP: MILD, TREATED AT HOME ®
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1. Parental reassurance and guidance regarding the course of
the disease and supportive homecare guidelines

2. Cool mist from a humidifier and/or sitting in a bathroom

filled with steam generated by running hot water from the
shower

3. Vaporizers (heated humidification) moisten the air but has

risk of scalding or burns, hence not recommended

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

CROUP: STEAM VERSUS COLD MIST ®

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1. Minimize crying by calming activities, stories

2. Antibiotics are not prescribed in mild croup

3. Single dose of oral Dexamethasone is recommended

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

STEAMER? ®
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MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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CROUP: HOME TREATMENT ®
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1. Fever with Acetaminophen or Ibuprofen
2. Encourage oral intake
3. Coughing can be treated with warm, clear fluids to loosen
mucus in the oropharynx
4. Avoid smoking in the home; smoke can worsen a child's
cough
5. At nighttime, parents/caregivers should with the ill child to
assess difficulty breathing

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

CROUP: MODERATE TO SEVERE CROUP ®

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• Significant respiratory distress /stridor at rest
• Refer
• Corticosteroids
• Nebulized epinephrine

• Antibiotics only for moderate-to-severe croup requiring

inpatient care

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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CROUP: CORTICOSTEROIDS ®
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• Corticosteroids indicated even for mild symptoms
• Prednisone, Dexamethasone both may be used
• Dexamethasone recommended due to longer half life and
higher potency
• Benefits:
1. Reduce symptoms of croup at 2 hours
2. Shorten hospital stay
3. Reduced the rate of return visits

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

CROUP: CORTICOSTEROIDS ®
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• A single dose of dexamethasone
• Best if given within the first 4-24 hours
• Half-life of Dexamethasone (36-54 h) covers the usual duration of
croup
• Dose of 0.6 mg/kg (OHGP 0.15 mg/kg) (both doses are effective)
• Same efficacy of IV, IM, or PO
• The route of administration depends on
1. Age
2. Ability to tolerate orals
3. Severity of illness

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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CROUP: PREDNISOLONE ®
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• Single oral dose of Prednisolone (1-2 mg/kg) can be used
• But causes more return visits due to

1. Lesser potency
2. Shortened half-life of prednisolone (18-36 h)

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

CROUP: RACEMIC EPINEPHRINE ®

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• Nebulized racemic epinephrine is a 1:1 mixture of dextro (D)
isomers and levo (L) isomers of epinephrine
• L form (L-epinephrine) as the active component
• Typically reserved for patients in the hospital setting with
moderate-to-severe respiratory distress
• Its effectiveness is immediate (within 30 minutes) lasting 1.5-
2 hours

• Not available in Pakistan

• Can use regular epinephrine

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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CROUP | REFERRAL ®
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• Refer if:
1. Cyanosis
2. Intercostal recession
3. Resting stridor
4. Child’s carers are unable to cope

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

SUMMARY: CROUP ®
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Mild Croup Moderate to severe Croup
Cool mist Cool mist
Paracetamol Paracetamol
Warm fluids Warm fluids
Dexamethasone Dexamethasone
Racemic epinephrine
Antibiotics
Referral
Monitoring
MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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BRONCHIOLITIS: A LRTI ®
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MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

BRONCHIOLITIS | A LOWER RTI ®

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• Occurs in children under 2 years of age
• Most commonly in the first year of life
• Peak between 3 and 6 months
• Occurs in epidemics—usually in winter
• Symptoms usually peak between 3 and 5 days
• Mostly caused by Respiratory Syncytial Virus (RSV)

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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BRONCHIOLITIS | CLINICAL FEATURES ®
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• Coryza (1–3days) followed by persistent cough
• Rapid breathing ± feeding difficulty
• May present with apnea

• EXAMINATION:
− Recession
− Tachypnoea
− Widespread crepitations/wheeze
− Fever (usually <39°C—if higher consider pneumonia)
− Pulse oximetry

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

NICE: DIAGNOSIS ®
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• Diagnose bronchiolitis if the baby or child has a coryzal
prodrome lasting 1 to 3 days, followed by:

1. Persistent cough and

2. Either tachypnoea or chest recession (or both) and
3. Either wheeze or crackles on chest auscultation (or both).

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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NICE: BRONCHIOLITIS VERSUS PNEUMONIA ®
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• Consider a diagnosis of pneumonia if the baby or child has:

1. High fever (over 39°C) and/or

2. Persistently focal crackles.

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

NICE: BRONCHIOLITIS VERSUS ASTHMA/VIRAL ®

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• Think about a diagnosis of viral-induced wheeze or
early-onset asthma rather than bronchiolitis in older infants
and young children if they have:

1. Persistent wheeze without crackles or

2. Recurrent episodic wheeze or
3. A personal or family history of atopy

The above conditions are unusual in children under 1 year of age

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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BRONCHIOLITIS | REFERRAL ®
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1. Looks seriously unwell
2. Lethargy/exhaustion
3. Grunting
4. Marked intercostal recession
5. Cyanosis
6. Peripheral O2 saturation <92%
7. Apneic episode
8. Respiratory rate >70 breaths/min(reported or observed)

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

BRONCHIOLITIS | HIGH RISK PATIENTS ®

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• Infants at increased risk of severe disease:
1. Premature babies
2. Very young babies (<12wk old)
3. Any underlying lung disease
4. Congenital heart disease
5. Neuromuscular disease
6. Immunosuppression

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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BRONCHIOLITIS | NICE ®
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MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

BRONCHIOLITIS | NICE ®
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MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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BRONCHIOLITIS | MANAGEMENT ®
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HOME MANAGEMENT
• If feeding well, no/mild recession
• Advise parents
• How to recognize worsening symptoms
• Not to smoke in the home
• How to call for help

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

NICE ®
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• Do not use any of the following to treat bronchiolitis:
1. Antibiotics
2. Hypertonic saline
3. Adrenaline (nebulized)
4. Salbutamol
5. Montelukast
6. Ipratropium bromide
7. Systemic or inhaled corticosteroids
8. Combination of systemic corticosteroids/nebulized
adrenaline

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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NICE ®
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• Give oxygen supplementation if oxygen saturation is:

• Persistently < 90%, (Aged 6 weeks and over)

• Persistently < 92%, (aged under 6 weeks or children of any age

with underlying health conditions. [2021]

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

BRONCHIOLITIS | PROGNOSIS ®
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• Most recover in < 14 days
• Up to 50% wheeze with subsequent URTIs

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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BRONCHIOLITIS: SUMMARY ®
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• Bronchiolitis is inflammation of the bronchioles which are
lowest and smallest part of respiratory tree
• Bronchioles take part in ventilation hence child may have low
saturation in bronchiolitis
• Oxygen remains the main stay of treatment
• Prognosis is good

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

REACTIVE AIRWAY DISEASE ®

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Airway hyperresponsiveness due to inflammation. Multiple
causes
1. Viruses
2. Bacteria
3. Post bronchiolitis
4. Irritants like those for asthma e.g., pollen, fumes, smoke, Pet
dander, cockroach and dust mite allergen
5. Exercise
6. Weather changes
7. Stress

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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DIFFERENCE BETWEEN RAD AND ASTHMA ®
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• Asthma is a Reactive Airway Disease, but not all RAD are not
asthma

• Asthma and RAD have similar clinical presentation, preventive

measures and treatment

• Asthma is diagnosed after five years of age

• Often, the term "reactive airway disease" is used when

asthma is suspected, but not yet confirmed.

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

REACTIVE AIRWAY DISEASE ®

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• Not all children who wheeze have asthma
• Most children younger than 3 years who wheeze are not
predisposed to asthma
• Having history of first wheeze before 1 year of age is a good
prognostic sign
• Only 30% of infants who wheeze go on to develop asthma

• Reactive airway disease has a large differential diagnosis and

must not be confused with asthma

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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REACTIVE AIRWAY DISEASE | CRITERIA ®
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To establish the diagnosis of asthma, certain criteria should be
met:
1. At least 5 years of age
2. Episodic symptoms of airflow obstruction or airway
hyperresponsiveness
3. Reversible airflow obstruction of at least 12% of predicted
forced expiratory volume in one second (FEV1) after use of
short-acting beta2-agonist
4. Alternative diagnoses have been excluded

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

REACTIVE AIRWAY DISEASE | HISTORY ®

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The following information should be elicited:

• URI symptoms
• Precipitating factors
• Use of a bronchodilator inhaler

• Date of last ED visit; how severe the current episode is

compared with previous episodes

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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REACTIVE AIRWAY DISEASE | MANAGEMENT ®
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• Treatment of the cause of RAD
• Treatment as for asthma
• Prevent an exacerbation from occurring
• Control triggers

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

RAD: SUMMARY ®
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• RAD is clinical condition caused by many etiologies
• One of the etiologies is asthma
• Pathophysiology of inflammation of bronchi and
bronchospasm make RAD and asthma very similar in diagnosis
and treatment
• RAD occur before 5 year of age and asthma is diagnosed after
5 years of age

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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CHILDHOOD PNEUMONIA ®
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MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

CHILDHOOD PNEUMONIA | ETIOLOGY ®

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• Viral
• Bacterial
- Pneumococcal
- Staphylococcal
- Hemophilus influenza
- Atypical (e.g., mycoplasma)

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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CHILDHOOD PNEUMONIA | PRESENTATION ®
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• Presents with ≥1 of:
1. Fever >38.5°C
2. Cough
3. Tachypnoea
4. Recession
5. Other signs of respiratory difficulty
− Crepitations
− Decreased breath sounds
− ± bronchial breathing

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

CHILDHOOD PNEUMONIA ®
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MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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OPACIFICATION, AIR BRONCHOGRAM ®
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MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

COMMUNITY ACQUIRED PNEUMONIA | Mx ®

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• Advice regarding fever and hydration management
• Amoxicillin is first-line
• Co-Amoxiclave is second line
• Consider Macrolides if
- Penicillin allergic
- Mycoplasma
- Chlamydia

• Advise parents to seek further medical review if no better in

<48h or worse in the interim

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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CHILDHOOD PNEUMONIA ®
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PREVENTION
• Pneumococcal vaccination at 2, 4, and 12 months
• Hib vaccine in Pentavalent vaccine
• Mask
• Respiratory hygiene
• Hand hygiene

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

LARYNGOTRACHEOMALACIA ®
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MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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LARYNGOTRACHEOMALACIA | ETIOLOGY ®
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• Common in small babies
• Congenital laryngeal stridor

• CAUSE:
- Due to floppy larynx and small soft airway

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

LARYNGOTRACHEOMALACIA | PRESENTATION & Mx ®

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• STRIDOR becomes more noticeable during
- Sleep
- Crying
- Excitement
- With concurrent URTIs

• Normally resolves without treatment

• Parental concern may necessitate REFERRAL

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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REFERENCES ®
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• https://www.nice.org.uk/guidance
• https://www.patient.co.uk
• https://www.aafp.org
• https://www.mayoclinic.org
• https://www.medscape.com
• https://www.who.int
• https://www.webmd.com
• Oxford Handbook of General Medicine, 5th edition

MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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MCPS-MRCGP[INT]-CEFM | Paediatrics | Respiratory | Topic

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