Makindo Medical Notes

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🧒 Lower Respiratory Tract Infections (LRTIs) are a major cause of childhood morbidity worldwide. 👉 Viral infections predominate in < 2 years (e.g., bronchiolitis), while bacterial causes become more relevant in older children. ⚠️ Always ensure follow-up if symptoms persist after discharge, as complications (empyema, post-infectious wheeze, bronchiectasis) may develop.

🦠 Causes

• Bacterial Causes:
  • 🟠 Pneumococcus: Major cause of bacterial pneumonia; lobar consolidation, pleural effusion possible.
  • 🟡 Mycoplasma pneumoniae: “Atypical” pneumonia in school-aged children with slow onset, dry cough, headache.
  • 🟢 Haemophilus influenzae (esp. non-typable): Important in unvaccinated children; can cause severe pneumonia.
  • 🔴 Staphylococcus aureus: Aggressive, necrotising pneumonia; classically post-influenza, with pneumatocoeles or empyema.
  • ⚫ Tuberculosis: Chronic cough, weight loss, night sweats in endemic areas or high-risk groups.
• Viral Causes:
  • 🟢 Respiratory Syncytial Virus (RSV): Leading viral LRTI cause under 2 years → bronchiolitis with wheeze & apnoea risk.
  • 🟠 Influenza A & B: Sudden high fever, myalgia, coryza → secondary bacterial pneumonia risk.
  • 🟡 Parainfluenza: Classically linked with croup but can cause bronchiolitis/pneumonia.
  • 🔵 Adenovirus: Severe LRTI; risk of chronic lung damage (bronchiectasis, obliterative bronchiolitis).
  • 🟣 Human Metapneumovirus: RSV-like illness; peak in winter/spring.
  • ⚪ Seasonal Coronaviruses: Usually mild, but can mimic RSV in infants.

📋 Signs and Symptoms

• General: 🌡️ Fever, malaise, poor feeding, irritability in infants.
• Respiratory Distress:
  • 📈 Tachypnoea (age-specific cut-offs per WHO/NICE).
  • 💙 Cyanosis (late sign of hypoxaemia).
  • 🔊 Grunting (attempt to increase PEEP).
  • ⬇️ Intercostal recession, nasal flaring, head bobbing.
  • 💪 Use of accessory muscles.
• Older children: Lobar signs – pleuritic chest pain, bronchial breathing, dullness to percussion, crackles.

📊 Monitoring

• 🌡️ Temperature (T): trends for fever.
• ❤️ Pulse rate (P): tachycardia may suggest fever, dehydration, or sepsis.
• 🫁 Respiratory rate (R): key for severity scoring.
• 📉 SpO₂: hypoxaemia < 92% = admit.

🏥 Admission Criteria

• SpO₂ < 92% persistently.
• Severe respiratory distress (grunting, head bobbing, cyanosis).
• Apnoeas or inability to feed.
• Concerns re: social support, poor follow-up, or significant comorbidities (CHD, immunosuppression).

🧪 Investigations

• Not routinely needed in mild CAP managed at home.
• Consider in hospitalised/severe cases:
  • 📸 Chest X-ray – if hypoxic, severe, or poor response.
  • 🩸 FBC & CRP – may help bacterial vs viral but not definitive.
  • 💉 Blood cultures / sputum (if possible).
  • 🧪 Viral PCR (RSV, influenza) in admitted infants – guides cohorting/isolation.

💊 Management

• Viral LRTI (esp. < 2 years):
  • Supportive care: fluids, oxygen, NG feeding if poor intake.
  • No role for antibiotics unless bacterial superinfection suspected.
  • RSV prophylaxis (Palivizumab) in high-risk infants (e.g., preterm, congenital heart disease).
• Bacterial CAP:
  • First-line (UK, per NICE): Amoxicillin oral.
  • Severe/hospitalised: IV co-amoxiclav or cefuroxime.
  • Atypical suspicion (school age, extrapulmonary features): add macrolide (azithromycin, clarithromycin).
  • Staph suspicion (rapidly worsening, pneumatocoele): flucloxacillin IV.

⚠️ Complications

• Empyema, lung abscess.
• Sepsis, septic shock.
• Post-infectious wheeze, bronchiolitis obliterans (adenovirus).
• Recurrent pneumonia → consider immunodeficiency, cystic fibrosis.

✅ Key Learning Points

• Most preschool LRTIs are viral – avoid overuse of antibiotics.
• Always assess severity (feeding, SpO₂, recession, apnoea).
• Admit if hypoxic, distressed, or unable to feed.
• Use antibiotics judiciously – amoxicillin for bacterial CAP, macrolides for atypical pathogens.
• Arrange follow-up if symptoms persist beyond expected course.