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Respiratory Diseases in Respiratory Diseases in ChildrenChildren
Christine T. Quien-Sua, MD DPPS DPAPPChristine T. Quien-Sua, MD DPPS DPAPP
Pediatric PulmonologyPediatric Pulmonology
January 18, 2010January 18, 2010
NOSEMOUTHVOCAL CORDSWIND PIPE
BRONCHI
BRONCHIOLES
NOSEMOUTHVOCAL CORDSWIND PIPE
BRONCHI
BRONCHIOLES
ALVEOLI ALVEOLI
RESPIRATORY SYSTEMRESPIRATORY SYSTEM
Respiratory System:1. Upper respiratory tract2. Lower respiratory tract
Upper Respiratory Tract DisordersUpper Respiratory Tract Disorders
• Choanal atresia• Foreign body• Common cold• Sinusitis• Pharyngitis• Retropharyngeal/
lateral pharyngeal abscess
• Laryngomalacia• Croup• Acute Epiglotittis• Obstructive Sleep
Apnea
Choanal AtresiaChoanal Atresia
• Most common congenital anomaly of the nose• Bony (90%) or membranous (10%) septum• CHARGE syndrome - Coloboma, Heart ,
Atresia, Retarted growth, Genital and Ear• Clinically unilateral - asymptomatic bilateral - difficulty in breathing with cyanosis relieved when crying
Choanal AtresiaChoanal Atresia
Choanal AtresiaChoanal Atresia
• Diagnosis: inability to pass a catheter through each nostril 3-4 cm into the nasopharynx
rhinoscopy or HRCT scan
• Treatment: – Supportive: oral airway, intubation or
tracheostomy; NGT– Definitive: Surgery
Foreign Body (Nose)Foreign Body (Nose)• Symptoms:
– Local obstruction, sneezing, mild discomfort, pain
• Disk batteries – most dangerous because it leach in matters of hours
• Diagnosis:– Unilateral nasal discharge and/or obstruction– Nasal speculum/ otoscope
• Complications:– Tetanus– Toxic shock syndrome
The Common ColdThe Common Cold
• Most common upper respiratory tract infection (AURI), rhinitis, nasopharyngitis
• Viral illness – Rhinovirus - the most common pathogen– Coronavirus, RSV
• 6-7 colds / year• 10-15% of children have at least 12 infections
per year
The Common ColdThe Common Cold
• Sore or “scratchy” throat
• Nasal obstruction
• Rhinorrhea
• Cough
• duration - 1 week
• 10% - last for 2 weeks
Common coldCommon cold
• P.E. limited to the upper respiratory tract
• A change in color or consistency of the secretions is common during the course of illness and is NOT indicative of sinusitis or bacterial superinfection
Condition Differentiating Features
Allergic rhinitis Prominent itching and sneezingNasal Eosinophilia
Foreign body Unilateral, foul-smelling dischargebloody nasal secretions
Sinusitis Headache, facial pain, peri-orbital edema
Persistence of rhinorrhea or cough > 10-14 days
Strep. pharyngitis Nasal discharge that excoriates the nares
Pertussis Onset of persistent or paroxysmal cough
Congenital syphilis Persistent rhinorrhea ( snuffles) with onset in the first three months
Table 364-2 Conditions that May Mimic the Common Cold
p. 1390 Nelson Textbook of Pediatrics 17th edp
The Common Cold: TreatmentThe Common Cold: Treatment
• Fever - acetaminophen• Nasal obstruction -adrenergic agents as
decongestants • Rhinorrhea - first generation anti-histamine due to the
anticholinergic effect• Sore throat - mild analgesics• Cough - due to postnasal drip; due to virus-induced
reactive airway disease-antihistamine/bronchodilator
Ineffective Treatments:• Vitamin C• Guaifenesin• Inhalation of warm, humidified air• Zinc• Echinacea -herbal treatment
The Common Cold: TreatmentThe Common Cold: Treatment The Common Cold: TreatmentThe Common Cold: Treatment
Common cold: ComplicationsCommon cold: Complications
• Otitis media - most common• Sinusitis• Asthma exacerbation• Inappropriate us of antibiotics –
antibiotic resistance
SinusitisSinusitis
• Etiology: viral or bacterial• Clinical signs suggestive of acute bacterial sinusitis
– Persistent signs/symptoms of URTI of > 14 days without improvement
– Severe respiratory symptoms (e.g. temp >39 C)– Purulent nasal discharge for 3-4 consecutive days
• Common bacterial pathogens of acute sinusitis Streptococcus pneumonia H. influenza Moraxella catarrhalis
SinusitisSinusitis
• Persistent symptoms of URI – nasal congestion/discharge, fever & cough
• Less common symptoms: halithosis, decreased sense of smell, periorbital edema
• P.E. mild erythema/swelling of nasal mucosa with nasal discharge
• Sinus tenderness in adolescents
Diagnosis: SinusitisDiagnosis: Sinusitis
• Transillumination of sinus cavities
• Sinus plain films and CT scan– Opacification, mucosal thickening, presence
of air-fluid level
• Sinus aspirate culture– not practical for routine use
Sinusitis - TreatmentSinusitis - Treatment
• Amoxicillin (45mkday)• Amoxicillin-clavulanate (80-90mkday)• Cephalosphorins• Clarithromycin, Azithromycin
• Duration: continue for 7 days after resolution of symptoms
Sinusitis - ComplicationsSinusitis - Complications
• Eye complications: – peri-orbital/ orbital cellulitis
• Intracranial complications: – Meningitis– cavernous sinus thrombosis– abscess
Acute pharyngitisAcute pharyngitis
• Etiology: Group A beta-hemolytic Streptococcus (GABHS) , virus
• Uncommon before 2-3 years old
• Peak incidence: 4-7 years old
• Sore throat as the primary symptom
Viral pharyngitisViral pharyngitis
• Presence of 2 or more of these signs and symptoms suggest viral infection:– Conjuctivitis - stomatitis– Rhinitis - discrete ulcerative lesions– Cough - viral exanthem– Hoarseness diarrhea– Coryza
Streptococcal pharyngitisStreptococcal pharyngitis
• M protein- major virulence factor that resists phagocytosis
• Physical examination:– red pharynx– enlarged tonsils with yellow blood-tinged exudate– petechiae on the soft palate and posterior pharynx– enlarged/tender anterior cervical lymph nodes
• Diagnosis: Throat culture - gold standard
Streptococcal pharyngitisStreptococcal pharyngitis
TreatmentTreatment
• Penicillin V -250mg/dose bid or tid x 10 days • Amoxicillin - 750mg OD x 10d 50mkday bid x 6 days • Benzathine Pen IM - 600,000 U for < 27kgs - 1.2M units• Erythromycin 40mkday tid or qid x 10days
Strep. pharyngitisStrep. pharyngitis
• Prevention of acute rheumatic fever is successful if treatment started within 9 days of illness
• Clindamycin (20mkday) -
recommended for carriers
Retropharyngeal and lateral Retropharyngeal and lateral pharyngeal abscesspharyngeal abscess
• ETIOLOGY:– Complication of bacterial pharyngitis– Extension of infection from vertebral osteomyelitis– Dental infection– Trauma
• Group A hemolytic strep., anaerobes, Staph. aureus
• Clinical manifestations:– With hx of acute nasopharyngitis– Abrupt onset of fever, difficulty of swallowing,
refusal to feed, severe distress with throat pain, hyperextension of head, drooling
• P.E.– Bulge in posterior pharyngeal wall
Retropharyngeal and lateral Retropharyngeal and lateral pharyngeal abscesspharyngeal abscess
Retropharyngeal and lateral Retropharyngeal and lateral pharyngeal abscesspharyngeal abscess
• Lateral x-ray of the neck– Retropharyngeal soft tissue is thick– Retropharyngeal air– Loss of N cervical lordosis
• Treatment– IV antibiotics with or without surgical drainage– 3rd gen cephalosporins+ Sulbactam-ampi or
Clindamycin
Retropharyngeal and lateral Retropharyngeal and lateral pharyngeal abscesspharyngeal abscess
Retropharyngeal and lateral Retropharyngeal and lateral pharyngeal abscesspharyngeal abscess
LaryngomalaciaLaryngomalacia
• Most common congenital laryngeal anomaly• Most frequent cause of stridor in infants and
children• Stridor appear at 2 weeks of life• Increase in severity up to 6 months• Diagnosis: flexible bronchoscopy• Treatment: observation - spontaneously resolve
Acute Inflammatory Upper Acute Inflammatory Upper Airway ObstructionAirway Obstruction
Viral agents accounts for most acute infectious upper airway obstructions except in:
Diphtheria
Bacterial tracheitis
Acute epiglottitis
Laryngotracheobronchitis Laryngotracheobronchitis (Croup)(Croup)
• Heterogeneous group of mainly acute and infectious processes
• brassy or bark-like cough• hoarseness, inspiratory stridor, respiratory distress• Parainfluenza viruses (type 1,2,3) - 75% of cases• age group: 3 mos - 5 y/o • peak 2y/o• Diagnosis is clinical
Soft tissue neck radiographSoft tissue neck radiograph
Laryngotracheobronchitis Epiglotittis
“steeple sign” “thumb sign”Postero-anterior view lateral view
Croup -TreatmentCroup -Treatment• Airway• Cool mist• Nebulized racemic epinephrine
0.25 to 0.75mL of 2.25% of epi in 3mL NSS q 20mins
duration < 2 hrs• Corticosteroids
Dexamethasone IM - 0.6mg/kg single dose or 0.15mg/kg
Budesonide nebulized - 2mg• Helium-oxygen mixture
Acute EpiglottitisAcute Epiglottitis
• Etiology: H. influenza type B
• Clinically: high grade fever, fever, rapidly progressing dyspnea
• barking cough is rare
• PE: “cherry red”epiglottis
• lateral radiograph of the upper airway
TreatmentTreatment
• Establish the airway! • Don’t forget oxygen • Ceftriaxone, cefotaxime, sulbactam-
ampi for 7-10 days• Rifampicin prophylaxis
(20mg/kg OD x 4 days)
Bacterial TracheitisBacterial Tracheitis• Complication of a viral disease• Life-threatening • < 3 years old• High grade fever, brassy cough, respiratory distress,
“toxic” BUT does NOT drool and no dysphagia and can lie flat in bed
• copious purulent secretions with pseudomembrane• mucosal swelling at the level of cricoid cartilage• Etiology : Staphylococcus aureus• Treatment: Airway, antibiotics and O2 support
SuddenSlow/sudden
deterioration
InsidiousSuddenOnset
H. Influenzae
Grp A strep
M. Catarrhalis
S. Aureus
H. influenzae
Parainfluenza
Influenza
Adenovirus
RSV
? Viral
?airwayreactivity
Etiology
2 Š 6 yr1 mo Š 6 yr0-5 yr (peak 1-2yr)
6 mo Š 3 yrAge range
EpiglottitisBacterialTracheitis
LTBSpasmodicCroup
High fever
Toxic
Nonbarkingcough
Muffled voice
Drooling
Dysphagia
Sitting/leaningforward
High fever
Toxic
Barkingcough
Stridor
Hoarse
Low-grade fever
Nontoxic
Barking cough
Stridor
Hoarse
Afebrile
Nontoxic
Barking cough
Stridor Hoarse
ClinicalManifestations
Large epiglottis
Thick
Arytenoepi-glotticfolds
Subglottic narrowingIrregular trachealborder
Subglotticnarrowing
Subglotticnarrowing
Radiographicfindings
Markedleukocytosis
Bandemia
Normal-mild
Leukocytosis
Marked bandemia
Mild
Leukocytosis
Lymphocytosis
NormalCBC,differential
Cherry redepiglottis
Aryteno-epiglotticswelling
Deep red mucosa
Copious trachealsecretions
Deep red mucosa
Subglotticswelling
Pale mucosa
Subglotticswelling
EndoscopicFindings
EpiglottitisBacterialTracheitis
LTBSpasmodicCroup
UsualUsualOccasionalRareIntubation
Rapid (40 hr)Slow (1-2 wk)TransientRapidResponse
Intubation
Antibiotics Š
Cefotaxime,Ceftriaxone, S.Ampicillin
Intubation
Antibiotics -
Anti-Staph
Mist
Calm
Racemic Epi
? Steroids
Intubation (ifneccesary)
Mist
Calm
(occ) racemic
Epinephrine
(occ) steroids
Therapy
Obstructive Sleep ApneaObstructive Sleep Apnea
DEFINITION:
• Disorder of breathing during sleep with prolonged partial upper airway obstruction and/or intermittent complete obstruction that disrupts normal ventilation during sleep
OSAOSA
• Prevalence rate: 0.7% -3%
• Peak: preschool (2-5y/o) male = female
• Adenotonsillar hypertrophy – the most common anatomic predisposing factor
• REM sleep – the most common functional predisposing factor
OSAOSA
• No direct correlation between tonsil size and severity of OSA.
• Habitual snoring – most common symptom• Triad of symptoms:
– Snoring– Nocturnal breathing difficulties– Witnessed respiratory pauses
OSAOSA• Overnight recording of multiple physiologic
sensors during sleep (POLYSOMNOGRAPHY) – gold standard for diagnosis
• Treatment: Adenotonsillectomy
• Complications if untreated:– Failure to thrive– Pulmonary hypertension– Cor pulmonale
Disorders of the Lower Disorders of the Lower Respiratory TractRespiratory Tract
• Foreign body aspiration
• Bronchitis
• Bronchiolitis
• Pneumonia
• Bronchial Asthma
• Pneumothorax
• Acute Respiratory Distress Syndrome
Foreign Body AspirationForeign Body Aspiration
• Older infants and toddlers
• With or without history of choking
• May present with wheezing, stridor, chronic cough
• Most common : peanuts
• Chest x-ray: air trapping, atelectasis
• Rigid bronchoscopy – diagnostic and therapeutic
Acute BronchitisAcute Bronchitis
• Protracted cough lasting for 1-3 weeks• Damaged or hypersensitized tracheobronchial
epithelium • Preceded by a viral URTI• afebrile, cough ( dry or purulent) , chest pain• PE: coarse and fine crackles , wheezing• Chest xray: Normal or increase bronchial
markings• IMPORTANT to exclude pneumonia• Self - limited and require NO treatment
Acute BronchiolitisAcute Bronchiolitis
• Common disease of the lower respiratory tract in infants
• Age group: 3 months - 2 y/o• Etiology: Respiratory syncytial virus (RSV)• Clinical: fever, rhinorrhea --- gradual
respiratory distress, dyspnea and irritability • Absence of other systemic complaints as
diarrhea or vomiting
Acute BronchiolitisAcute Bronchiolitis
• PE: tachypnea, nasal flaring, retractions predominantly wheezing
• Chest radiograph: hyperinflation with patchy atelectasis
Bronchiolitis-TreatmentBronchiolitis-Treatment• The first 48-72hrs after onset of cough
and dyspnea is the most critical• Humidified O2• Position - head and chest elevated and
neck extended• NPO and IV fluids• Bronchodilators and nebulized
epinephrine• Ribavirin - thru aerosol tx used for infants
with CHD and chronic lung disease• Corticosteroid and antibiotics - NO benefit
Bronchiolitis and AsthmaBronchiolitis and Asthma
• Higher incidence of wheezing and asthma in children with a history of bronchiolitis
• Even in patients with no family history of asthma or atopy
Bronchial AsthmaBronchial Asthma
A disorder of the tracheobronchial tree characterized by:
• reversible airway obstruction
• airway hyperreactivity
• airway inflammation
A child with one affected parent has 25 % risk of having asthma, the risk increases to 50 % if both parents are asthmatic
Clinical Manifestation of AsthmaClinical Manifestation of Asthma
• cough
• breathlessness
• tachypnea
• dyspnea
• Hyperinflation
• Wheezing - cardinal sign of asthma
Diagnosis of AsthmaDiagnosis of Asthma
• History and physical examination
• PEFR (> 20% change)
• Spirometry
• Therapeutic trial
Triggers of AsthmaTriggers of Asthma
Classification of AsthmaClassification of Asthma
• intermittent
• persistent – mild– moderate– severe
TreatmentTreatment
• Family education• Avoidance of triggers• Bronchodilators
– B2 agonist - short acting & long acting
• Corticosteroids– Inhaled– oral
Differential Diagnosis of WheezingDifferential Diagnosis of Wheezing
• Gastro-esophageal Reflux Disorder
• Vascular Ring
• Foreign Body
• Congenital Heart Disease
PneumoniaPneumonia• Inflammation of the parenchyma of the lungs• Significant cause of morbidity and mortality in
childhood• Community acquired pneumonia (CAP) - 44-85% due
to virus and bacteria• Viral pneumonia - major cause BPN in children
younger than 5 y/o• Peak attack rate 2-3y/o• RSV - major pathogen• Parainfluenza, Influenza and Adenovirus
Pneumonia - etiologyPneumonia - etiology
• Consider the age, immunization status and health status of the child
• 2-3y/o - H. influenza type b
• > 5 y/o - Strep pneumonia, M. pneumonia, Chlamydia pneumonia
Clinical Symptoms of Clinical Symptoms of PneumoniaPneumonia
• Triad of fever, cough and tachypnea• Tachypnea - most consistent clinical
manifestation of pneumonia• PE: crackles, rhonchi, decreased breath
sounds
Chest radiographChest radiograph
• Confirms the diagnosis of pneumonia
• Indicate the presence of complications
• Not diagnostic if used alone
Viral pneumoniaViral pneumonia
• hyperinflation• bilateral interstitial
infiltrates • peri-bronchial
cuffing
Bacterial pneumonia - consolidationBacterial pneumonia - consolidation
Diagnosis -PneumoniaDiagnosis -Pneumonia
• Definitive diagnosis - isolation of microorganism
• blood culture is positive only in 10-30% of cases
• sputum culture - no clinical use
Differential diagnosis of pneumonia by Etiologic Differential diagnosis of pneumonia by Etiologic CategoryCategory
Signs and symptoms
Bacterial Viral Chlamy-
dial
Mycoplasma TB
History Afebrile
INFANCY
Age any Any
<2y
1-4mos School age
adolescent
Any
>4mos
Onset sudden gradual gradual gradual Gradual/acute
cough Productive Dry cough
Dry cough-only symptom
Dry cough productive
Other signs Pleuritic chest pain
Coryza
Sore throat, rash
conjunctivitis
Sore throat rash, bullous OM
headache
Weight loss, night sweats
Signs and symptoms
Bacterial Viral Chlamy-
dial
Mycoplas-ma
TB
Fever Toxic
High grade
Nontoxic
Low grade
afebrile Low grade
Variable
Lung auscultation
Rales
Decreased breath sounds
Rales
Wheezing
rhonchi
Rales
wheezing
Rales variable
WBC increased Normal
sl. inc
Normal
Eosino-philia
Atypical lymph
variable
Other lab test Blood cs Nasal washing Nasal washing
Cold aggluti-nation test
AFB, PPD
Culture
Xray Consolidation, effusion, pneumatoces, abscess
Hyper-inflation
Interstitial infiltrates
Hyper-inflation
Interstitial infiltrates
variable variable
Treatment - PneumoniaTreatment - Pneumonia
• Amoxicillin - 30-50mkday tid - 80-90mkday (penicillinase-resistant)
• Cefuroxime• Co-amoxiclav
Complication of PneumoniaComplication of Pneumonia
• Due to direct spread of bacterial infection within the thoracic cavity– Pleural effusion– Empyema– Lung abscess
• S. aureus & S. pneumonia - most common cause of empyema
Pleural effusion, right
Parapneumonic EffusionParapneumonic Effusion
• Thoracentesis –diagnostic and therapeutic
• Diagnostic: pleural fluid analysis
• Usually exudative– Pleural fluid/serum protein >0.5– Pleural fluid/serum LDH > 0.6– Pleural fluid LDH > 2/3 upper normal– pH < 7.2
Complicated Parapneumonic Complicated Parapneumonic effusion or Empyemaeffusion or Empyema
• Treatment:– Therapeutic thoracentesis– Tube thoracostomy– Tube thoracostomy with intrapleural fibrinolytics– Thoracoscopy with breakdown of adhesions– Thoracoscopy with decortication
PneumothoraxPneumothorax
• Accumulation of extrapulmonary air within the chest
• May be primary or secondary
• May be sponteneous, traumatic, or iatrogenic
• Onset is usually abrupt and severity of symptoms depends on the extent of collapse lung
PneumothoraxPneumothorax
PneumothoraxPneumothorax
• Observation
• 100% oxygenation
• Simple aspiration
• Thoracostomy
• Pleurodesis
Acute Respiratory Distress Acute Respiratory Distress Syndrome (ARDS)Syndrome (ARDS)
• Impaired oxygenation with PaO2/ FiO2 ratio of less than 200
• Chest xray with bilateral densities
• Pulmonary artery wedge pressure less than 28mm Hg
• No clinical evidence of left atrial hypertension
Type of Cough
Likely Responsible Condition
Loose (discontinous), productive
Bronchitis, asthmatic bronchitiscystic fibrosis, bronchiectasis
Brassy tracheitis, habit cough
With stridor laryngeal obstruction, pertussis
Paroxysmal (with or without gagging or vomiting)
cystic fibrosis, pertussis syndrome, foreign body
Staccato Chlamydial pneumonitis
Nocturnal Upper or lower respiratory tract allergic reaction or both, sinusitis
Most severe on awakening in morning
cystic fibrosis, bronchiectasis, chronic bronchitis
With vigorous exercise
exercise-induced asthma, cystic fibrosis, bronchiectasis
Disappears with sleep
habit cough, mild hypersecretory states such as asthma and cystic fibrosis
Tight ( wheezy )
reactive airways
Good Luck!!!Good Luck!!!