Respiratory Airway Infections Infections
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General Goal: To know the cause(s) of these diseases, the most common modes of transmission, and the major manifestations of these diseases.

Specific Educational Objectives: The student should be able to:

1. recite the common cause(s), the common means of transmission, and identify the major disease manifestations.

2. determine based on clinical manifestations if a patient has one of these diseases as well as determine which disease they have acquired.

3. explain what is in the vaccines and why it is important to give the vaccines to people.

4. explain the 4 D's of epiglottitis. Know how to obtain the "thumb" and "steeple" signs and know what diseases these signs are present in.

5. describe how to avoid getting the various diseases if any prevention means are possible.

Reading: F.S. Southwick, Infectious Diseases in 30 Days, 1st edition, McGraw Hill. p. 107-153.

Lecture: Dr. Neal R. Chamberlain

References: 
Childhood vaccination schedule: http://www.immunize.org/cdc/schedules/




Overview

The respiratory airways discussed in this section of the handout include the airways from the epiglottis to the bronchioles. The infections discussed are croup (which includes acute laryngitis, laryngotracheobronchitis, and epiglottitis), acute bronchitis, bronchiolitis, influenza, and pertussis (Figure AI-1). All of the diseases discussed in this chapter, with the exception of epiglottitis and pertussis, are usually caused by viruses; epiglottitis and pertussis are caused by bacteria.

 

CROUP

Acute laryngitis, laryngotracheobronchitis (viral croup), and epiglottitis (bacterial croup) are acute inflammatory diseases, collectively called croup, and involve the upper airways. The most common and most serious risk of this group of diseases is obstruction of the airway. This risk is particularly important to remember when treating very young children because the airways of young child are narrower than the airways of older children and adults.

Etiology

Parainfluenza virus type I is the most common cause of viral croup (Table AI-1 for a list of other causes of viral croup and laryngitis).

 

Table AI-1. Other Causes of Viral Croup

Viruses

Parainfluenza virus type II, influenza virus types A and B, adenovirus, respiratory syncytial virus, herpes simplex virus, rhinovirus, coxsackievirus A and B, echovirus

Haemophilus influenzae type b is the most common cause of epiglottitis (bacterial croup; S pyogenes is second) (see Table AI-2 for a list of other causes of epiglottitis).

Table AI-2. Other Causes of Epiglottitis

Bacteria

Streptococcus groups A, B, and C , Nontypeable Haemophilus influenzae, Streptococcus pneumoniae, Klebsiella pneumoniae, Staphylococcus aureus, Haemophilus parainfluenza, Neisseria meningitidis

Viruses

Varicella zoster virus

Fungi

Candida albicans

 

Manifestations

 

Acute laryngitis

 

Acute laryngitis usually begins as an upper respiratory infection, followed by dysphonia (hoarseness) and reduced vocal pitch or aphonia. Other symptoms may include odynophonia (pain when speaking), dysphagia (difficulty swallowing), odynophagia (pain when swallowing), sore throat, congestion, fatigue, and malaise. Direct examination reveals diffuse laryngeal erythema and edema and vascular engorgement of the vocal folds.

 

Viral croup

 

Patients with viral croup or laryngotracheobronchitis have a fever (38–39°C), which is higher than occurs in laryngitis, restlessness and air hunger, which is more severe than occurs in laryngitis. Croup begins with a prodromal mild upper respiratory infection with coryza, nasal congestion, sore throat, and cough that lasts 2–3 days; this is followed by hoarseness and a harsh, brassy, “bark-like” cough. Respiratory stridor usually occurs at night, often awakening the child from sleep.

 

Physical examination of the patient with croup may reveal minimal distress to severe respiratory failure due to airway obstruction. In mild cases, the results of the lung examination at rest usually are normal; however, mild expiratory wheezing may he heard during auscultation. Children with severe croup have primarily inspiratory stridor at rest with nasal flaring and suprasternal and intercostal retractions. Lethargy or agitation may be a result of hypoxemia. Other warning signs of severe respiratory disease are tachypnea, tachycardia out of proportion to the presence of fever, lethargy, pallor, and hypotonia (decreased muscle tone). The child may be unable to maintain adequate oral intake and may become dehydrated. Cyanosis is a late and ominous sign. Croup symptoms usually peak over 3–5 days and resolve within 4–7 days.

 

Epiglottitis

 

Epiglottitis is a medical emergency and risk of mortality is extremely high. Signs and symptoms include acute onset and fever, sore throat, hoarseness, and a barking cough. There is retraction of the suprasternal notch and stridor with every breath. The throat is inflamed, and the epiglottis is swollen, stiff, and a beefy red color. The disease can progress rapidly resulting in toxicity, prostration, severe dyspnea, and cyanosis. The physician should be watchful for dysphagia, dysphonia, drooling, and distress—the four D’s.

 

Epidemiology

 

 

Viral croup and acute laryngitis

 

 

Epiglottitis

 

Pathogenesis

 

Children have narrower airways than adults, which results in an increased number of complications associated with viral croup and epiglottitis.

 

Viral infection of the upper airways causes inflammation and edema of the larynx in acute laryngitis, and viral infection in the larynx, trachea, and bronchi causes viral croup. Mucus is produced by the host and causes partial obstruction of the airway in both viral croup and acute laryngitis. Swelling of the vocal cords results in dysphonia. In viral croup, narrowing of the subglottic trachea in a child’s airway results in audible inspiratory stridor. As viral croup progresses, the lumen of the trachea becomes obstructed further by fibrous exudates. The barking cough that occurs in patients with viral croup is caused by inflammation in the larynx and trachea.

 

Epiglottitis is a cellulitis of the epiglottis and the surrounding tissues. H influenzae type b colonizes the pharynx. The organisms then colonize the epiglottitis and enter the tissues of the epiglottitis through minor breaks in the mucosal surface. The organisms grow in the tissues and cause an inflammatory response that result in erythema and edema. A sore throat rapidly progresses to difficulty breathing, stridor, obstruction of the airways, and respiratory arrest. Local extension from the colonized nasopharynx through soft tissues is likely to be the cause of epiglottitis.

Diagnosis

 

Diagnosis of acute laryngitis is based on the clinical signs and symptoms of the patient (see manifestations). Viral croup is diagnosed by hoarseness, barking cough, and inspiratory stridor and retractions, which indicate airway obstruction (Table AI-3). A patient with viral croup will usually experience less restlessness and air hunger following treatment with racemic epinephrine or water-saturated air. These treatments do not have any affect on a patient with bacterial epiglottitis. The steeple sign seen in an anteroposterior neck radiograph is characteristic of viral croup. Viral cultures usually are not obtained.

 


 

Table AI-3. Comparison of the Clinical and Radiologic Features of Viral Croup and Epiglottitis

 Clinical Features

Viral Croup

Epiglottitis

Etiology

Parainfluenza virus

Haemophilus influenzae type b

Age of patient

6 month–3 years

2–7 years

Onset of disease

Gradual

Sudden

Fever

Mild

> 38°C

Abnormal chest sounds

Bark-like cough, stridor

Muffled, guttural cough

Swallowing

Normal

Difficult, with drooling

Facies

Normal

Anxious, distressed, toxic

Response to racemic

epinephrine or

water-saturated air

Usually good;

Less air hunger and

restlessness

Usually poor;

Little to no effect on air hunger and restlessness

Radiology

Steeple sign in

anteroposterior neck

radiograph

Thumb sign in lateral radiograph

 

The patient with epiglottitis should be handled with extreme care because airway closure can occur simply by placing a tongue depressor in the patient’s mouth to examine the throat. Examination of the larynx can irritate the patient and cause airway closure and asphyxiation. Equipment for an emergency tracheostomy should be available during examination of a patient suspected of having epiglottitis. If the patient has bacterial epiglottitis, the etiologic agent should be determined. H influenzae type b, the most common cause of epiglottis, does not grow on blood agar, therefore, throat swabs and smears should be cultured on blood agar and chocolate agar plates. In epiglottitis, H influenzae is often in the bloodstream; therefore blood cultures are helpful. A leukocytosis can be seen in the complete blood count (CBC). A positive thumb sign on lateral radiographs of the neck is diagnostic of epiglottitis.

 

Therapy and Prevention

 

Acute laryngitis is a self-limiting infection, and symptomatic therapy usually is all that is necessary. Treatment of viral croup requires maintenance of an adequate airway as follows.

Proper care and handling of the patient with epiglottitis can determine whether the patient lives or dies. Treatment of epiglottitis involves securing the patient’s airway by intubation in surgery and antibiotic therapy with ampicillin/sulbactam, ceftriaxone, cefotaxime, or cefuroxime. Children should be sedated when being intubated to prevent them from pulling out the tube.

The Hib vaccine is the capsular type b polysaccharide conjugated to the diphtheria toxoid, and it has drastically reduced the incidence of epiglottitis in the US. A child who has not received the Hib vaccine and who is exposed to a patient with epiglottitis should receive chemoprophylaxis with rifampin.


Send comments and mail to Dr. Neal R. Chamberlain, nchamberlain@atsu.edu
Revised 8/7/13
©2010-2013 Neal R. Chamberlain, Ph.D., All rights reserved.