CASE: You are working after hours and a young mother brings her 12 month old infant with fever 104 C

Should you admit this patient and perform an infectious workup or send the patient home with close surveillance?

In any given year, 15% of visits to the ED or urgent care by children under 15 years of age are children with fever. The vast majority of these children have self-limited viral infections. Yet serious illness is also manifested by fever in children and includes meningitis, sepsis, and pneumonia. With increasing rates of vaccination against hemophilus and pneumococcus, invasive infection and meningitis have been declining. The most common serious infections are pneumonia in the less than three month group of infants and urinary tract infection in infants older than 3 months. Red flags indicating serious illness include any of the following:

• Change in sensorium
• Changes in crying/moaning patterns
• Cyanosis
• Rapid breathing and shortness of breath
• Hypotension
• Signs of meningeal irritation
• Rashes esp petechial
• seizures

This past year, the American College of Emergency Physicians[1] have released an updated clinical policy on evaluation of the child under two years with fever. Their recommendations are summarized below:

Infants 1-3 months: consider lumbar puncture (LP) to rule out meningitis in infants 29-90 days and admitted to hospital for observation. Antibiotics are appropriate after LP until cultures are returned as negative

Children 2 months – 2 years: perform a chest radiograph in children with fever of at least 100.4F with no clear infection source but have cough, rales or hypoxia. Do not perform CXR in children with fever and wheezing and high probability of bronchiolitis. Consider performing urinalysis and urine culture especially in high risk children including girls under 1 year, uncircumcised boys, fevers lasting longer than 24 hrs. and no clear infection source. If there is a positive urinalysis (leukocyte esterase or nitrates) start antibiotics without waiting on results of urine culture. AAP recommends collecting urine samples through cauterization or suprapubic aspirate.

If the infant or child presents during the influenza season, consider performing rapid influenza testing.

If serious infection is strongly considered, the following age grouped antibiotics are recommended:

Under 1 month                                                 Ampicillin + gentamicin or cefotaxime

Over 1 month with urinary:                         cefotaxime or cefixime

1-3 months possible meningitis                 ceftriaxone

1-3 months (listeria/enterococcus)          add ampicillin

3 months + pneumonia                                 amoxicillin or azithromycin

[1] Annals of Emergency Medicine, May 2016; 67(5): 625-639

CASE: Mr Dooby, a 52 year old male,  presents to your office with a chronic cough and shortness of breath with normal activities, worsening over the last 12 months. By history, he has been a pack per day smoker since he was 18 years of age.

Does this patient have chronic obstructive pulmonary disease?

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease characterized by chronic cough, shortness of breath with exertion or at rest. It is the 3^rd leading cause of death in the United States affecting 4-9% of the population with up to 90% of COPD cases related to smoking.  Diminished breath sounds, peak flow rates of under 350-l/min and a 30 pack year smoking history are 98% positively predictive. Diagnosis can be confirmed by spirometry with bronchodilators with an FEV1/FVC ratio of under 0.7 with increasing degrees of irreversibility (by bronchodilator). The GOLD classification is based on this latter index with the FEV1 % of predicted

> 80        mild

50-79     moderate

30-49     severe

< 30        very severe

The primary differential is with asthma which is characterized by reversibility and variability of airflow obstruction. Other conditions to consider include congestive heart failure, lung cancer, pulmonary arterial hypertension, interstitial lung disease and upper airway/ vocal cord dysfunctions.

The foundations of management include smoking cessation through tobacco cessation programs and pharmacotherapy with nicotine replacement, varnenicline, or buproprion. Also includes regular use of inhaled bronchodilators starting with short acting beta agonists or anticholinergics for mild COPD with addition of long acting beta agonist (LABA) or long acting anticholingerics. With progression of disease severity, additional of an inhaled corticosteroid in combination with a LABA is indicated.  Roflumilast (Daliresp) which is a phosphodiesterase-4 inhibitor should also be considered in severe or very severe COPD.

The role of oxygen has evolved with recommendations now to provide supplemental oxygen to patients with COPD who have severe resting hypoxia (O2 sat 88% or less). The key is to ensure that patients use oxygen for at least 15 hours per day to achieve target O2 saturations of 88-92%. Pulmonary rehab is also important for severe-very severe COPD patients. Mucolytics and anti-tussives are NOT recommended and provide little benefit.

As the disease progresses, consider providing or referring for palliative care. Use of the BODE Index allows you to determine the risk of dying in your COPD patients. BODE includes four variables: FEV1, six minute walk distance, MRC dyspnea score, and BMI. Scores indicate four year survival rates with 0-2 = 80% survival up to 7-10 18% survival.