FEVER AND COUGH

What is a cough?
• Definition: Sudden gush of air to partially close the glottis by
contraction of expiratory muscles
Differential Diagnosis for Causes of Cough
• Infections: Croup, Pneumonia, bronchiolitis, TB, pertussis, diphtheria,
sinusitis, tonsilitis, pharyngitis
• Inflammatory: Asthma, allergy
• Non-inflammatory: FB
• Traumatic: Pneumothorax
• Extra: Severe anemia, CHD, cardiac failure, GERD, postnasal drip
• Structural Anomalies: Tracheoesophageal fistula (at birth),
Laryngomalacia (6-8 weeks)
• Immunodeficiency: Bronchiectasis, ciliary dysplasia - Kartagener
• Ciliary dysplasia: congenital impairment of mucociliary
clearance. Inherited disease. E.g. Kartagener’s syndrome
• Postnasal drip: Body produces extra mucus – accumulates at
back of throat, put baby in prone position
• Laryngomalacia: congenital softening of the tissues of the larynx
(voice box) above the vocal cords
• Pertussis: severe coughing followed by a whoop, cyanosis, vomiting
(infants – pink)
• Diptheria: inspiratory stridor due to laryngeal edema
CROUP (Laryngotracheitis)
• Agents:
Parainfluenza 1,2,3
Respiratory Syncytial Virus
Rhinovirus
Enterovirus
Mycoplasma Pneumoniae
Staph aureus

• Inflammation of the larynx and subglottic airway characterized by a barking cough, inspiratory
stridor and hoarseness
• Common 6months – 3 years, severe in <2 years
• Diagnosis is clinical
SCORE SEVERITY DESCRIPTION MGX
<2 MILD Occasional barking cough, Home tx: PCT, fluids,
no stridor at rest, no or single dose dexa PO
mild retractions (0.6mg/kg) or
prednisolone PO (1mg/kg)
3-7 MODERATE Freq barking cough, Single dose dexa PO
stridor at rest, mild-mod Nebulized epinephrine
retractions, no or little Hospitalization if no
distress or agitation improvement
8-11 SEVERE Frequent barking cough, Single dose dexa
stridor at rest, marked (oral/IV/IMI)
retractions, significant Repeated doses nebulized
distress & agitation epinephrine
Inpatient tx
>12 IMPENDING RESP FAILURE Depressed consciousness, Single dose dexa (IV/IMI)
stridor at rest, severe Repeated doses nebulized
retractions, poor air entry, epinephrine
cyanosis/pallor ICU
Intubation
CROUP (WHO)
Mild: Fever, hoarse voice, barking/hacking cough, stridor when child is agitated
Severe: Stridor at rest, rapid breathing, lower chest indrawing, cyanosis or O2 sat <90%
Management:
Mild: Supportive care at home – breastfeeding, fluids
Severe:
1. Admit
2. Single dose dexa (0.6mg/kg) /prednisolone (1mg/kg) + nebulized budesonide (2mg)
3. Nebulized racemic epinephrine
4. Monitor need for intubation and/or tracheostomy – chest indrawing, restless
5. Assess resp status (Nurses every 3h, doctors twice daily)
6. Avoid oxygen unless there is complete airway obstruction
7. Supportive care (PCT >39, avoid cannulation, keep child calm, oral fluids, eat)
EPIGLOTTITIS
• Supraglottic
• Life threatening
• X-RAY: Steeple sign/wine bottle sign.
• 2-6 years (avg – 4 years)
Lat – swollen epiglottis – thumb sign
• Mainly HIB
Tx:
Clinical Features:
• Keep child calm
• Rapid and abrupt 3 Ds: Dysphagia, drooling,
distress • Single dose dexa shot (0.3-
0.6mg/kg)/prednisolone PO
• Very high fever (>39)
• DO NOT USE TONGUE DEPRESSOR
• Muffled voice/hot potato voice
• Maintain airway: Intubation +/- tracheostomy
• Dorsally held neck/tripod position: Trunk
leaning forward, neck hyperextended, chin • Ceftriaxone - HiB
thrust foward • No manipulation of airway at x-ray, supervise
• Soft stridor • Laryngoscopy confirms diagnosis
• Difficulty in breathing
• Lacks hoarseness of voice/cough
IMCI (2 months-5 years)
Pneumonia
Infection in lung parenchyma ->
Neutrophils -> Increased permeability
-> Cap leakage -> Plasma exudates in
alveoli ->Fluid build-up in spaces
between alveoli -> Consolidation
Risk Factors:
• Immunocompromised
• No immunization (HiB,
S.pneumoniae)
• Mechanical ventilation recently
• Recent antibiotics
Symptoms: (subtle)
• Fever + cough
• Others: tachypnea preceding,
difficulty feeding, restlessness,
abnormal breath sounds, pleuritic
chest pain
• Severe: stridor, indrawing, pleurisy –
feel & listen
Pneumonia
Examination Findings:
Vitals: Fever, tachypnea
Inspection: Indrawing
Palpation: Asymmetric expansion of chest wall, tactile Fremitus increased, pleural rub, coarse creps
Percussion: Dull
Auscultation: Bronchophony increased, bronchial breath sounds/coarse crackles, creps, wheezing/stridor, pleural rub – if
complicated

Differentiate coarse creps from pleural rub:

Pleural Rub: Pain – sleeps on affected side, tries to splint area when breathing, heard during inspiration & expiration, pushing
steth into chest wall and listening increases intensity of sound
Coarse creps: Heard at any phase

Bronchial Breath Sounds: During consolidation -> No air entry into the alveoli because of the exudates. Air movement in and out
of the bronchi instead of the lung parenchyma. Good medium/conductor: Consolidation, cavitation, collapse with a patent
bronchi in pleural effusion
Pneumonia Tx
Outpatient:
• Amox PO (40mg/kg twice daily for 5 days)
• Supportive Care
• F/Up

Severe:
• IV ampicillin (50mg/kg) /benzyl penicillin (IV every 6h for at least 5 days) + genta
(7.5mg/kg IM/IV OD for at least 5 days)
• Failure of first line -> Ceftriaxone (80mg/kg IM/IV OD)
• Supportive care: O2, PCT, IVF, bronchodilator for wheezing, feeding
• Monitor (3hrly by nurses, twice daily by doctor)
Pneumonia Complications
• Pleural Effusion: PE: asymmetric movement of chest wall, tracheal deviation,
decreased tactile fremitus, stony dull, decreased bronchophony, vesicular breath
sounds. X-Ray: Blunting of cardiophrenic angle, costodiaphramatic recesses.
Meniscus sign
• Empyema: Mainly same as PE. Persistent fever despite 48 hrs ABs; USS- localized
• Lung Abscess: PE: Low grade fever, foul smelling and bad-tasting, cough, same as
pneumonia. X-ray: cavity w/ air-fluid level, thin-thick-walled.
• Pneumatocele: Seen in S.aureus pneumonia. Thin walled air fluid cysts
• Pyeopneumothorax: Infected pneumothorax
• Acute Respiratory Failure
CAUSES OF WHEEZING
• Definition: continuous musical sound due to narrowing of airway.
Occurs on inspiration +/- expiration
• <2 years: acute viral resp infections - bronchiolitis, cold
• >2 years: asthma, pneumonia, FB, GERD, tumors, trauma
BRONCHIOLITIS
• <2 years
• Disease of terminal bronchioles
• Agents: RSV, rhinovirus, parainfluenza virus, adenovirus, mycoplasma pneumonia
• Pathophysiology: Colonizes nasopharynx -> inflammation -> release of cytokines -> increases thermoregulatory setpoint
of the hypothalamus -> Fever; plasma leakage -> Rhinorrhea/congestion. Travels to lower airways -> destroys ciliated
epithelium of bronchioles -> impaired mucous clearance -> cough. Build up of mucus -> Narrowing of airway -> Tubulent
airflow -> wheeze. Mucus production -> Crackles
• C/F: Rhinorrhea/congestion, cough, mild wheezing/rhonchi (not relieved with 3 doses bronchodilators), fever, fine
crackles, hyperinflation of chest, increased resonance on percussion, indrawing, difficulty in feeding – owing to respiratory
distress
• Mgx:
Admit if severe signs of pneumonia present/danger signs/gasping or grunting
Supportive care: O2 therapy (if less than 90%)
Same antibiotics as pneumonia (according to WHO, Dr Dubey said no)
Fever > 39: PCT
Monitor
Self-limiting and subsides in 3-7 days
Discharge when resp distress and hypoxemia have resolved. F/up if danger signs, advise that cough and wheeze can last up
to 6 weeks
BRONCHIOLITIS VS
BRONCHOPNEUMONIA
Bronchiolitis
• Sweating – sympathetic activity
• Anxious
• Catarrhal stage – sneezing,
coughing, rhinorrhea initially
• Sibilant rhonchi – high pitched,
shrill, continuous whistling
• Fine creps
• Severe resp distress
disproportionate to chest
findings
Bronchopneumonia
• Toxic looking
• Widespread non-homogenous
patchy opacities – milliary
shadowing
• Polymorphic leukocytosis
• Can be viral but mostly bacterial
Management of acute SOB
• Primary survey
• Physical examination
• Chest X-ray to confirm
ASTHMA
• Chronic cough + supporting symptoms (dry cough, wet-concurrent infection),
wheezing, dyspnea, atopy – rhinitis, rash, trigger), triggered with infection,
relieved by bronchodilators
• Clues: Hx, family hx
• Evaluation:
1. PE: Tactile fremitus N/increased, hyperresonance on percussion, Bronchophony
N/increased, wheeze – mostly prolonged expiratory, decreased breath sounds
2. Chest x-ray: Bilateral hyperinflation, changes within rt middle lobe
3. Spirometry: >6 years [obstructive pattern – reversible]
• Trial of asthma medication – supports diagnosis
PEAK FLOW METER
• Move the marker to the bottom of the numbered scale.
• Stand up straight.
• Take a deep breath. Fill your lungs all the way.
• Hold your breath while you place the mouthpiece in your mouth, between your
teeth. Close your lips around it. DO NOT put your tongue against or inside the hole.
• Blow out as hard and fast as you can in a single blow. Your first burst of air is the
most important. So blowing for a longer time will not affect your result.
• Write down the number you get. But, if you coughed or did not do the steps right, do
not write down the number. Instead, do the steps over again.
• Move the marker back to the bottom and repeat all these steps 2 more times. The
highest of the 3 numbers is your peak flow number. Write it down in your log chart.
F/up Plan for Asthma (Asthma note for
caregiver)
1. Triggers
2. Meds w/ spacer
3. Diary/peak flow
4. Danger signs
5. Review (1-6 months)
Asthma Meds:
Drug
Muscarinic Antagonists –
ipratropium bromide
SABA - salbutamol
LABA - salmeterol
Corticosteroids – inhaled/systemic
Methyl Xanthines - theophylline
Mast Cell Stabilizers
Desensitization Therapy
MOA Side Effects
Inhibits receptors in bronchial Dry mouth, blurred vision,
smooth muscles - bronchodilation constipation
B2 agonists - bronchodilation Palpitations, tremors, tachy
bronchodilation Palpitations, tremors, tachy
Inhibits transcription factors – HTN, osteoporosis, Cushing
decreased expression of pro-
inflammatory cells
Inhibits phosphodiesterase –
increase Camp – anti-inflammatory
and mild broncodilation
Prevents release of inflammatory Cough, nasal & throat irritation
mediators from mast-cells
Takes 3 years, not commonly used
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DIAGNOSING TB
• In children: pauci-bacillary, low immunity
• Triad: Recent close contact, +ve TST – screening, +ve chest findings: Xray/PE
• Hx: chronic cough, weight loss, night sweats, fever, exposure
• Physical Exam
• Screening: TST (doesn’t differentiate latent from ongoing)
• Confirm bacteriologically (Sputum induction: Fast child ->aerosolized ketosaline +
salbutamol ->Suction OR Gastric aspirate – Gene xpert)
• Pulmonary vs extrapulmonary: Chext x-ray (Ghon complex), CT Scan
• What is a ghon/primary complex? Ghon focus, hilar lymph node, lymphatics
• What is Interferon Gamma Release Essay:
Better specificity, like TST, requires only 1 visit
DOTS
• Directly observed treatment short course
• Includes supervision + pt support
• For adherence, side effects, MDR prevention, dosage and timing,
monitoring
• Pt + trained volunteer/health worker
• Daily/1st day of week/alternate days
• Temperature and weight taken everyday (intensive) Assess every 2/12
(continuation phase)