Upper Respiratory Tract Infection

Features of respiratory disorders in children are:

- Worldwide, they cause more than 750 000 deaths per year in children aged
from 1 month–5 years old
- They may be account for half of consultations with general practitioners for
acute illness in young children and a third of consultations in older children
- They are common and responsible for about 25% of acute paediatric
admissions to hospital
- Asthma is the most common chronic illness of childhood
- Modern management of cystic fibrosis has markedly extended life
expectancy.
Presentation of respiratory disorders in children is with:
- Upper respiratory tract symptoms of coryza, sore throat, earache, sinusitis or
stridor
- Lower respiratory tract symptoms of cough, wheeze and respiratory distress.
- As children, especially infants, have compliant chest walls and poorly
developed respiratory muscles, they are particularly susceptible to respiratory
failure
- Early detection and prevention are the cornerstone of management.
Presentation of respiratory disorders in children is with:
- Moderate: tachypnoea, tachycardia, nasal flaring, use of accessory
respiratory muscles, intercostal and subcostal recession, head retraction and
inability to feed
- Severe: cyanosis, tiring because of increased work of breathing, reduced
conscious level, O2 saturation < 92% despite oxygen therapy.
- Monitoring SO2 to detect hypoxaemia and to titrate the amount of O2
required.
- Respiratory support, either non-invasive or invasive ventilation may be
required.
- Signs of respiratory distress may become less marked when children become
exhausted.

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 - Children who are particularly susceptible to respiratory failure include ex-
preterm infants with bronchopulmonary dysplasia, those with
haemodynamically significant CHD causing muscle weakness, cystic fibrosis
or immunodeficiency.

Physiology of respiratory symptoms

Physiology of stridor and wheeze
- Inspiration is an active process in which the contraction and downward
movement of the diaphragm combines with the upward and outward
movement of the ribs to generate a negative pressure in the thoracic cavity,
which sucks air into the lungs through the tube of the extrathoracic airways.
- A gradient of negative pressure is formed from the alveoli to the upper
airway.
- Within the thoracic cavity the airway walls are pulled outwards by the
negative intrathoracic pressure.
- Above the thoracic inlet, where the external pressure is atmospheric, the
negative pressure within the airways leads to a degree of inward collapse
during inspiration.
- The reverse happens during expiration, when the recoil pressure of the chest
wall generates a positive intrathoracic pressure and pushes air out from the
alveoli to the upper airway, compressing the intrathoracic airways but
distending the extra thoracic airway.
- These changes are exaggerated during any form of airway obstruction, since
the pressures generated to overcome the obstruction are even higher.
- Obstruction to extra thoracic airways is worse during inspiration, whereas
obstruction to the intrathoracic airways worse during expiration.
- Stridor from extra thoracic airway obstruction in the trachea and larynx, is
predominantly inspiratory, and wheeze, from intrathoracic airway narrowing,
is predominantly expiratory, it is harsh and musical.
- Snoring is inspiratory, it is caused by variable partial upper airway
obstruction, it is a rough inspiratory noise (Stertor) with lacks a single note
- Narrowing of the airway due to inflammation is a feature of many respiratory
pathologies
- Upper airway narrowing results in increased effort and added respiratory
noises during inspiration

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 - Lower airway narrowing results in increased effort and added respiratory
noises during expiration, such as crepitations and wheeze

Upper respiratory tract infection

- Children have a median of five upper respiratory tract infections (URTIs) per
year in the first few years of life, but some toddlers and primary school-aged
children have as many as 10–12 per year.
- Approximately 80% of all respiratory infections involve only the nose, throat,
ears or sinuses.
- The term URTI embraces a number of different conditions:
1. Common cold (coryza)
2. Sore throat (pharyngitis, including tonsillitis)
3. Acute otitis media
4. Sinusitis (relatively uncommon).
- The most common presentation is a child with a combination of these
conditions.
- Cough may be troublesome and in URTI may be secondary to postnasal drip or
attempts to clear upper airway secretions.
- URTIs may cause:
1. Difficulty in feeding in infants as their noses are blocked and this
obstructs breathing
2. Febrile seizures
3. Acute exacerbations of asthma.
- Hospital admission is rarely required but may be necessary if feeding and fluid
intake is inadequate.

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 The common cold (coryza)
- It is the most common infection of childhood.
- The most common pathogens are viruses: rhinoviruses, coronaviruses and
respiratory syncytial virus (RSV).
- Classical features include a clear or mucopurulent nasal discharge and nasal
blockage.
- Cough may persist for up to 4 weeks after a common cold.
TTT:
1. Health education to advise parents that colds are self-limiting and have no
specific curative treatment may reduce anxiety and save unnecessary visits
to doctors.
2. Pain is best treated with paracetamol or ibuprofen.
3. Antibiotics are of no benefit as the common cold is viral in origin and
secondary bacterial infection is very uncommon.

Sore throat (pharyngitis and tonsillitis)

- In pharyngitis, the pharynx and soft palate are inflamed and local lymph nodes
are enlarged and tender.
- Tonsillitis is a form of pharyngitis where there is intense inflammation of the
tonsils, often with a purulent exudate.
Causative organism:
- Viral: adenoviruses, enteroviruses, and rhinoviruses).
- In older child: group A β-haemolytic streptococcus is a common
pathogen.
Clinical picture:
- Marked constitutional disturbance, such as headache, apathy and
abdominal pain, white tonsillar exudate and cervical lymphadenopathy, is
more common with bacterial infection.

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Treatment:
1) Antibiotics (e.g. penicillin V or erythromycin if there is penicillin allergy)
are often prescribed for severe pharyngitis and tonsillitis.
2) In order to eradicate the organism completely (and prevent rheumatic fever)
10 days of antibiotic treatment is required for pharyngitis or tonsillitis.
3) Rarely, in severe cases, children may require hospital admission for
intravenous fluid administration and analgesia if they are unable to swallow
solids or liquids.
4) Amoxicillin is best avoided as it may cause a widespread maculopapular
rash if the tonsillitis is due to infectious mononucleosis.

Acute otitis media

- Most children will have at least one episode of acute otitis media.
- Up to 20% will have three or more episodes.
Age: This is most common at 6–12 months of
PPF: Infants and young children are prone to acute otitis media because their
Eustachian tubes are short, horizontal, and function poorly.
Pathogens include viruses, especially RSV and rhinovirus, and bacteria including
pneumococcus, Nontypeable Haemophilus influenzae and Moraxella catarrhalis.

DIAGNOSIS
- There is pain in the ear and fever.
- Every child with a fever must have his/ her tympanic membranes examined
- by examining the tympanic membrane.
- In acute otitis media, the tympanic membrane is seen to be bright red and
bulging with loss of the normal light reflection.
- Occasionally, there is acute perforation of the eardrum with pus visible in the
external canal.

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- Otitis media with effusion is the most common cause of conductive hearing
loss in children and can interfere with normal speech development and result in
learning difficulties in school.
- The eardrum is seen to be dull and retracted, often with a fluid level visible.
- Otitis media with effusion is very common between the ages of 2–7 years, with
peak incidence between 2.5–5 years of age.
FATE
1. It usually resolves spontaneously, but may cause conductive hearing loss.
2. Serious complications are mastoiditis and meningitis, but these are now
uncommon.
3. Most cases of acute otitis media resolve spontaneously.
4. Recurrent ear infections can lead to otitis media with effusion (also called glue
ear).
TREATMENT
1. Children are usually asymptomatic apart from possible decreased hearing.
2. A reasonable approach is to give the parents a prescription but ask them to use
it only if the child remains unwell after 2–3 days.
3. Pain should be treated with an analgesic such as paracetamol or ibuprofen.
4. Regular analgesia is more effective than intermittent (as required) and may be
needed for up to a week until the acute inflammation has resolved.
5. Antibiotics marginally shorten the duration of pain but have not been shown to
reduce the risk of hearing loss.
6. Amoxicillin is widely used.
7. Neither decongestants nor antihistamines are beneficial.
8. Cochrane reviews have shown no evidence of long-term benefit from the use of
antibiotics, steroids, or decongestants.
9. In children with effusion, insertion of ventilation tubes is often performed,
but benefits do not last more than 12 months.
10.Antibiotics marginally shorten the duration of pain but do not reduce hearing
loss.
11.If recurrent, may result in otitis media with effusion, which may cause speech
and learning difficulties from hearing loss.

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 Sinusitis
- Infection of the paranasal sinuses may occur with viral URTIs.
- Occasionally, there is secondary bacterial infection, with pain, swelling and
tenderness over the cheek from infection of the maxillary sinus.
- As the frontal sinuses do not develop until late childhood, frontal sinusitis is
uncommon in the first decade of life.
- Antibiotics and analgesia are used for acute sinusitis.
Tonsillectomy and adenoidectomy
- Children with recurrent tonsillitis are often referred for removal of their tonsils,
one of the most common operations performed in children.
- Many children have large tonsils, usually reaching a maximum size at about 8
years but this in itself is not an indication for tonsillectomy as they shrink
spontaneously in late childhood.
- The indications for tonsillectomy are controversial, and must be balanced
against the risks of surgery, but include:
Indications for tonsillectomy
1. Recurrent severe tonsillitis: At least 7 episodes in the previous year, at
least 5 episodes in each of the previous 2 yr, or at least 3 episodes in each of
the previous 3 yr
2. A peritonsillar abscess (quinsy)
3. Obstructive sleep apnoea (the adenoids will also often be removed).
Adenoidectomy
- Adenoids increase in size until about the age of 8 years and then
gradually regress.
- In young children, the adenoids grow proportionately faster than the
airway, so that their effect of narrowing the airway lumen is greatest
between ages 2–8 years.
Indications for the removal of both the tonsils and adenoids include:
1. Recurrent otitis media with effusion with hearing loss, where it gives a
significant long-term additional benefit
2. Obstructive sleep apnoea (an absolute indication).
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 Stridor
DEF: Stridor is a harsh, musical sound due to partial obstruction of the lower
portion of the upper airway including the upper trachea and the larynx.
- The most common cause is laryngeal and tracheal infection.
- The severity of upper airways obstruction is best assessed clinically by
characteristics of the stridor (none, only on crying, at rest, or biphasic) and the
degree of chest retraction (none, only on crying, at rest).
- Severe obstruction leads to increasing respiratory rate, heart rate, and agitation.
- Central cyanosis, drooling or reduced level of consciousness suggest
impending complete airway obstruction.
- The most reliable measure of hypoxaemia is by measuring the oxygen
saturation by pulse oximetry, but it is a late feature of upper airways
obstruction.
- Total obstruction of the upper airway may be precipitated by examination of the
throat using a spatula.

Differential diagnosis of acute stridor

Upper airway obstruction
1. Common causes
- Viral laryngotracheobronchitis (‘croup’)
2. Rare causes
1. Epiglottitis
2. Bacterial tracheitis
3. Laryngeal or oesophageal foreign body
4. Allergic laryngeal angioedema (seen in anaphylaxis and recurrent croup)
5. Inhalation of smoke and hot fumes in fires
6. Trauma to the throat
7. Retropharyngeal abscess
8. Hypocalcaemia
9. Severe lymph node swelling (tuberculosis, infectious mononucleosis,
malignancy)
10.Measles
11.Diphtheria
12.Psychological – vocal cord dysfunction

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 Croup
- Viral croup accounts for over 95% of laryngotracheal infections.
- Parainfluenza viruses are the most common cause, but other viruses, such
as rhinovirus, RSV and influenza, can produce a similar clinical picture.
- Croup typically occurs from 6 months to 6 years of age but the peak
incidence is in the 2nd year of life.
- It is most common in the autumn.

The typical features are coryza and fever followed by:

a) Hoarseness due to inflammation of the vocal cords
b) A barking cough, like a sea lion, due to tracheal Oedema and collapse
c) Harsh stridor
d) Variable degree of difficulty breathing with chest retraction
e) The symptoms often start, and are worse, at night.
f) When the upper airway obstruction is mild, the stridor and chest
recession disappear when the child is at rest and the child can usually be
managed at home.
g) The parents should observe the child closely for signs of increasing
severity.
h) The decision to manage the child at home or in hospital is influenced by
1. The severity of the illness
2. The time of day
3. Ease of access to hospital
4. The child’s age (with more admission for those <12 months old due to
their narrow airway calibre)
5. Parental understanding
6. Confidence about the disorder.

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TTT
1. Inhalation of warm moist air is a traditional and widely used therapy but not
beneficial.
2. Oral dexamethasone, oral prednisolone, or nebulized steroids (budesonide)
reduce the severity and duration of croup and are first-line therapy for
croup causing chest recession at rest.
- They reduce the need for hospitalization.
3. In severe upper airways obstruction, nebulized epinephrine (adrenaline)
with oxygen by face mask provides rapid but transient improvement.
4. The child must continue to be observed closely for 2–3 hours after
administration as the effects wear off.
5. Intubation for viral croup has become extremely unusual since the
introduction of steroid therapy.
6. Some children have a pattern of recurrent croup, which may be related to
atopy.
Acute epiglottitis
- In acute epiglottitis there is intense swelling of the epiglottis and surrounding
tissues associated with septicaemia.
- It is a life-threatening emergency due to the high risk of respiratory
obstruction.
- It is caused by H. influenzae type b (Hib).
- Introduction of universal Hib immunization in infancy has led to more than
99% reduction in the incidence of epiglottitis and other invasive Hib infections.
- Epiglottitis is most common in children aged 1–6 years but affects all age
groups.
- The onset of epiglottitis is usually very acute with:
1. High fever in a very ill, toxic-looking child
2. An intensely painful throat that prevents the child from speaking or
swallowing; saliva drools down the chin
3. Soft inspiratory stridor and rapidly increasing respiratory difficulty over
hours

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 4. The child sitting immobile, upright, with an open mouth to optimize the
airway.

Croup Epiglottitis

Onset Over days Over hours

Preceding coryza Yes No

Cough Severe, barking Absent or slight

Able to drink Yes No

Drooling saliva No Yes

Appearance Unwell Toxic very ill

Fever <38.5° C >38.5° C

Stridor Harsh, rasping Soft, whispering

Voice cry Hoarse Muffled reluctant to Speak

PRECAUTION
- Attempts to lie the child down or examine the throat with a spatula or perform a
lateral neck X-ray to identify a swollen epiglottis and surrounding tissues must
not be undertaken as they can precipitate total airway obstruction and death.
MANAGEMENT
- If the diagnosis of epiglottitis is suspected, urgent hospital admission and
treatment are required.
- The child should be intubated under controlled conditions with a general
anaesthetic.
- Rarely, this is impossible and urgent tracheostomy is life-saving.
- Only after the airway is secured should blood be taken for culture and
intravenous antibiotics such as cefuroxime started.
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- The tracheal tube can usually be removed after 24 hours and antibiotics given
for 3–5 days.
- With appropriate treatment, most children recover completely within 2–3 days.
- As with other serious H. influenzae infections, prophylaxis with rifampicin is
offered to close household contacts.
-

Bacterial tracheitis
(pseudomembranous croup)
- This rare but dangerous condition is similar to severe epiglottitis in that the
child has a high fever, appears very ill, and has rapidly progressive airways
obstruction with copious thick airway secretions.
- It is typically caused by infection with Staphylococcus aureus.
- Management is by intravenous antibiotics and intubation and ventilation if
required.

Other causes of stridor

- When a child with acute stridor presents with atypical features or a poor
response to treatment, other causes need to be considered.
- If a child has an abrupt onset of stridor without apparent infection, consider
anaphylaxis or inhaled foreign body.
Chronic stridor
is usually due to a structural problem, either from intrinsic narrowing or collapse of
the laryngotracheal airway, e.g. subglottic stenosis, laryngomalacia, or external
compression (e.g. vascular ring, lymph nodes, tumours).
Investigations are required to determine the cause
Basic management of acute upper airways obstruction is:
a) Reduce anxiety by being calm, confident, and well organized
b) Observe carefully for signs of hypoxia or détérioration – agitation or
fatigue or drowsiness or cyanosis.
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 c) Provide oxygen if required and tolerated
d) Do not examine the throat with a spatula!
1. It may precipitate upper airway obstruction
2. Oral, nebulized or intravenous steroids are beneficial in croup and have
similar speed of onset (90–120 min)
3. If severe, administer nebulized epinephrine (adrenaline) and contact an
anaesthetist
4. If respiratory failure develops from increasing airways obstruction,
exhaustion or secretions blocking the airway, urgent tracheal intubation is
required.

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 Summary
The child with stridor
A. Croup:
1. Mostly viral
2. 6 months to 6 years of age
3. Harsh, loud stridor
4. Coryza and mild fever, hoarse voice, barking cough

B. Epiglottitis:
1. Caused by H. influenzae type b, rare since Hib immunization
2. Mostly aged 1–6 years
3. Acute, life-threatening illness
4. High fever, ill, toxic-looking
5. Painful throat, unable to swallow saliva, which drools down the chin

C. Bacterial tracheitis:
1. High fever, toxic
2. Loud, harsh stridor

D.Inhaled foreign body:

1. Choking on peanut or toy or object in mouth
2. Sudden onset of cough or respiratory distress

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 Croup Epiglottitis Bacterial Foreign Body
Tracheitis

Swallowing Normal Drooling Normal Variable, usually

(dysphagia) normal

Barking Yes No Yes Variable; brassy if

cough tracheal

Toxicity Rare Severe Severe; may No, but dyspnea

also manifest
toxic shock
syndrome

Fever <38.3°C >38.9°C > 38.9°C None

X-ray Subglottic Thumb sign of Ragged Radiopaque object

narrowing; thickened irregular may be seen
steeple sign epiglottis tracheal
border; as per
croup

WBC count Normal Leukocytosis Leukocytosis Normal

with left shift with left shift

Therapy Racemic Endotracheal Antibiotics; Endoscopic

epinephrine intubation, intubation if removal
aerosol, ceftriaxone needed
systemic
steroids,
aerosolized
steroids, cold
mist

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Prevention None H. influenzae None Avoid small
b conjugated objects; supervision
vaccine

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