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Respectfully,
Donna D’Alessandro, MD

Patient Presentation
A pediatrician was traveling on a long-haul train when it began to become very cold in the car. He overheard the train steward responding to a passenger complaint about the temperature who said, “This is the temperature we set it at to decrease the spread of diseases.” A half-hour later after the car had warmed up, he also heard the steward saying that, “The conductor had turned on the air conditioning airflow by mistake, but that we usually have a set temperature to stop the spread of diseases.” The pediatrician had no idea what temperature would decrease the risk of disease and wrote down the question to research later.

Discussion
Ambient comfort levels depend on many factors including the temperature, humidity, airflow, radiant heat, and clothing of the individual among others.

In the United States Department of Labor’s, Occupational Health and Safety Administration (OSHA) states As a general rule, office temperature and humidity are matters of human comfort. OSHA has no regulations specifically addressing temperature and humidity in an office setting…. OSHA recommends temperature control in the range of 68-76° F [20-24.4° C] and humidity control in the range of 20%-60%.”

In the United Kingdom, the temperature usually should be at least 16 deg C [60.8°F] and at least 13 [55.4°F] if much of the work is physical. Where it is not appropriate, such as a cold storage room, bakery, etc., reasonable accommodations should be provided rotating tasks, insulating of pipes, providing shading on windows, etc..

Learning Point
According to the Centers for Disease Control guidelines for environmental infection control in health care settings: “Cool temperature standards (68°F-73°F [20°C-23°C]) usually are associated with operating rooms, clean workrooms, and endoscopy suites. A warmer temperature (75°F [24°C]) is needed in areas requiring greater degrees of patient comfort. Most other zones use a temperature range of 70°F-75°F (21°C-24°C).”

Humidity “[f]or most areas within health-care facilities, the designated comfort range is 30%-60% relative humidity.” Ventilation and pressurization of rooms has many parameters that are outlined in the guidelines (see To Learn More below).

Questions for Further Discussion
1. What temperature related issues does an airline need to consider for its passenger compartment ambient temperature?
2. What environmental controls can decrease disease spread risk in contained areas such as a train, bus, plane?

Related Cases

Disease: Ambient Temperature | Hypothermia | Heat Illness |
Infection Control | Occupational Health for Healthcare Providers

Symptom/Presentation: Health Maintenance and Disease Prevention

Specialty: Infectious Diseases | Preventive Medicine and Health Maintenance

Age: Young Adult

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Hypothermia and Heat Illness.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC). Guidelines for Environmental Infection Control in Health-Care Facilities.
Available from the Internet at http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_hcf_03.pdf (rev. 6/6/2013, cited 4/2/2013).

United States Department of Labor. Occupational Health and Safety Administration. OSHA Policy on Indoor Air Quality: Office Temperature/Humidity and Environmental Tobacco Smoke.
Available from the Internet at http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=24602 (rev. 2/24/2003, cited 4/2/2013).

Health and Safety Executive. What is the maximum/minimum temperature in the workplace?
Available from the Internet at http://www.hse.gov.uk/contact/faqs/temperature.htme (cited 4/2/2013).

ACGME Competencies Highlighted by Case

Patient Presentation
A 21-month-old male came to an outside emergency department with fever, difficulty swallowing, and neck stiffness. The plain radiograph of the neck showed concern for a retropharyngeal abscess and the patient was transferred by helicopter for surgical evaluation and treatment. The radiologic evaluation at the referral hospital of a neck computed tomographic examination revealed an enlarged hypodense area anterior to the cervical vertebra with ring enhancement consistent with the diagnosis of signficant retropharyngeal abscess. He was taken to the operating room where a combined team of pediatric otolaryngologists and pediatric surgeons performed a transoral and lateral neck drainage of a significant retropharyngeal abscess. The patient was intubated for airway control because of the extent of the abscess but was extubated on post-operative day 2. The cultures grew methicillin-sensitive Staphylococcal aureus and the patient received a total of 10 days IV antibiotics and an additional 1 week of oral antibiotics. He was sent home with an additional 1 week of oral antibiotics and the patient’s clinical course at 1 week after discharge found him doing well.

Figure 107 – CT examination of the neck performed with intravenous contrast shows a large retropharyngeal abscess that extends from the skull base to the mediastinum that displaces and compresses the airway and esophagus (top), which involves the carotid spaces bilaterally as well as the retropharyngeal space (middle), and encases the trachea and mediastinal vessels (bottom).

Discussion
Retropharyngeal abscesses (RPA) occur in the potential space bound anterior to the prevertebral fascia, posterior to the pharyngeal constrictor muscles and their fascia and laterally by the carotid sheaths and parapharyngeal space (another potential space lying laterally to the pharynx). The retropharyngeal potential space runs superiorally from the base of the skull to the mediastinum distally. It is the most common deep neck infection. In children under 4 years of age, retropharyngeal lymph nodes are present which regress after this age. RPA is most common in young children when these lymph nodes are present, with probable suppuration of these lymph nodes and extension of the infection. RPAs in children are most commonly preceded by an upper respiratory tract infection (45%) such as tonsillitis, pharyngitis, sinusitis or cervical lymphadenitis, a foreign body ingestion (27%) or idiopathic (28%) in one study. Adults have more history of trauma or instrumentation preceding RPA. The organisms most commonly associated with RPA are mixed oral flora with gram-positive organisms such as Streptococcus viridians, Staphylococcus aureus, and Staphylococcus epidermidis being common. Gram-negative organisms include Haemophilus influenza, Bacteroides species and Fusobacterium species. Similar organisms are seen in peritonsilar abscess also.

It can be difficult to discern other common infections from RPA as many patients will show fever, decreased oral intake, neck lymphadenopathy, neck swelling and sore throat. Patients who also show neck pain with movement, torticollis, trismis, drooling, dysphonia or stridor may be easier to recognize, but other severe infections such as laryngotracheobronitis, epigottitis and meningitis may also show these symptoms.

Evaluation includes many indications of infection and inflammation such as complete blood count, erythrocyte sedimentation rate and C-reactive protein but are not specific. Radiological methods are most helpful. Plain lateral soft tissues radiographs can show anterior widening of the soft tissue space and narrowing of the airway. Plain radiographs are 80-88% sensitive and 100% specific. Ultrasound can be used but can be difficult to obtain and a negative examination does not rule out RPA. Computed tomography is considered the gold standard for diagnosis with a homogenous hypodense mass with ring enhancement.

Treatment is with intranvenous antibiotics and most often surgical drainage via a transoral route but also lateral neck and/or extension into the chest cavity may be necessary. Supportive measures such as intubation or tracheostomy may also be necessary.

Learning Point
Complications of RPAs include upper airway obstruction, jugular vein thrombosis, vascular rupture and hemorrhage, bacteremia, septic shock, mediastinitis, pericarditis, pleural empyema, aspiration pneumonia (due to spontaneous rupture), meningitis, and epiglottitis. Recurrence occurs in 1-5% of patients. Death can occur in up to 40-50% of patients. Higher death rates are seen in adults than children.

Questions for Further Discussion
1. What antibiotics would be appropriate for empiric treatment of a retropharyngeal abscess?
2. Describe the common location of a peritonsilar abscess?

Related Cases

Disease: Retropharyngeal Abscess | Abscesses | Throat Disorders

Symptom/Presentation: Fever and Fever of Unknown Origin | Neck Stiffness

Specialty: Critical Care | Emergency Medicine | Otolaryngology | Radiology / Nuclear Medicine / Radiation Oncology | Surgery

Age: Toddler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Abscess and Throat Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Wang LF, Kuo WR, Tsai SM, Huang KJ. Characterizations of life-threatening deep cervical space infections: a review of one hundred ninety-six cases. Am J Otolaryngol. 2003 Mar-Apr;24(2):111-7.

Philpott CM, Selvadurai D, Banerjee AR. Paediatric retropharyngeal abscess. J Laryngol Otol. 2004 Dec;118(12):919-26.

Al-Sabah B, Bin Salleen H, Hagr A, Choi-Rosen J, Manoukian JJ, Tewfik TL. Retropharyngeal abscess in children: 10-year study. J Otolaryngol. 2004 Dec;33(6):352-5.

Brook I. Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses. J Oral Maxillofac Surg. 2004 Dec;62(12):1545-50.

ACGME Competencies Highlighted by Case

Patient Presentation
A 4 month old male came to the emergency room with fever to 103° and cough for 48 hours. The coughing had been much worse over the past day but there was no apnea or cyanosis. The patient had not had anything to drink for the past 8 hours. The past medical history showed a full-term infant without neonatal problems. He was current on immunizations. The family history showed no pulmonary disease.

The pertinent physical exam revealed a tired appearing male with a respiratory rate of 62, pulse of 114, with normal blood pressure and temperature. His pulse oximeter was 88% on room air. His capillary refill was 3 seconds. HEENT showed clear rhinitis. Lungs had some mild coarse breath sounds throughout the fields with decreased sounds on the right. The rest of his examination was normal. The work-up included a venous blood gas of pH= 7.34, CO2 = 38 and O2 of 56 with a base of -6. A respiratory viral panel was negative for influenza, respiratory syncytial virus and other viruses. A pertussis nasal swab was also negative. The radiologic evaluation of a chest radiograph showed a right upper lobe consolidation with a moderate apical/anterior pneumothorax and small pneumomediastinum. The diagnosis of bilateral lower lobe pneumonia and spontaneous pneumothorax and pneumomediastum was made. He was treated conservatively with oxygen at 100% by nasal canula, IV fluids and antibiotics for community-acquired pneumonia. He was slowly improving clinically after 5 days.

Figure 105 – 06-20-13 – AP view of the chest demonstrates right upper lobe collapse, patchy bibasilar infiltrates felt to represent bacterial pneumonia, and pneumomediastium outlining the inferior border of the heart – a continuous diaphragm sign.
Figure 106 – 06-20-13 – Left lateral decubitus view of the chest demonstrates a small right pneumothorax.

Discussion
“A pneumothorax is a collection of air in the pleural space, and it can be categorized into spontaneous, traumatic or iatrogenic. Spontaneous pneumothorax can be further classified into primary with no clinical evidence of underlying lung disease or secondary due to pre-existing lung disease.”

Spontaneous pneumothorax is a condition that is relatively rare in pediatrics. There is a bimodal age distribution – neonates and late adolescence. It is caused by tearing of the visceral pleural. Clinical signs include chest pain, dyspnea, tachycardia, tracheal deviation towards contralateral side, hypotension, cyanosis.

There is a wide variation in treatment practices particularly for large pneumothoraces. For small ones, most are treated conservatively with or without oxygen therapy, and treatment for an underlying cause if present. Large pneumothoraces can be treated conservatively, by aspiration, chest tube, pleurodesis and/or surgery. The pneumothorax is seen on AP radiographs, but decubutus radiographs often make the pneumothorax more prominent. Because air will track anteriorly on a supine chest radiograph often used in small children, pneumothorax in these children can easily be missed on the AP but not on the decubitus radiograph.

To review the complications of pneumonia and its common infectious disease causative agents, see What Are the Complications of Pneumonia?.

Learning Point

Causes of secondary spontaneous pneumothorax include:

• Airway disease
  • Asthma, associated with
  • Bronchopulmonary dysplasia
  • Bronchiectesis
  • Cystic fibrosis
• Congenital lung disease
  • Congenital lobar emphysema
  • Cystic adenomatoid malformation
• Interstitial lung disease
  • Saroidosis
  • Langerhans cell histiocytosis
• Infectious disease
  • Measles
  • Pneumonia or abscess
  • Pneumocystis jirovecii
  • Parasitic, especially ecchinococcal
  • Tuberculosis
• Connective tissue disease
  • Marfan
  • Dermatomyositis
  • Ehler-Dahlos
  • Polymyositis
  • Systemic lupus erythematosis
• Other
  • Catamenial pneumothorax or intrathoracic endometriosis
  • Foreign body
  • Malnutrition

Questions for Further Discussion
1. What is the pathophysiology behind treating with oxygen for pneumothorax?
2. How should a recurrent pneumothorax be treated?

Related Cases

Disease: Spontaneous Pneumothorax | Pleural Disorders | Lung Disease

Symptom/Presentation: Fever and Fever of Unknown Origin | Respiratory Distress

Specialty: Allergy / Pulmonary Diseases | Radiology / Nuclear Medicine / Radiation Oncology | Surgery

Age: Infant

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Pleural Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Michel JL. Spontaneous pneumothorax in children. Arch Pediatr. 2000 Mar;7 Suppl 1:39S-43S.

O’Lone E, Elphick HE, Robinson PJ. Spontaneous pneumothorax in children: when is invasive treatment indicated? Pediatr Pulmonol. 2008 Jan;43(1):41-6.

Robinson PD, Cooper P, Ranganathan SC. Evidence-based management of paediatric primary spontaneous pneumothorax. Paediatr Respir Rev. 2009 Sep;10(3):110-7.

Roberts D, Wacogne I. Question 3. In patients with spontaneous pneumothorax, does treatment with oxygen increase resolution rate? Arch Dis Child. 2010 May;95(5):397-8.

Kurihara M, Kataoka H, Ishikawa A, Endo R. Latest treatments for spontaneous pneumothorax. Gen Thorac Cardiovasc Surg. 2010 Mar;58(3):113-9.

ACGME Competencies Highlighted by Case