United Airways Module

A Module For The Practicing PediatricianUnder The IAP Presidential Action Plan 2018

TeamDesignation Name

Chairperson Dr Santosh SoansCo-chairperson Dr Sachidanand Kamath IAP Coordinator Dr Bakul ParekhNational Coordinator Dr Jose OusephJoint National Coordianator Dr Salim A KhatibNational Scientific Convener Dr S Balasubramanian Jt. National Scientific Convener Dr S. Nagabhushana

Zonal ConvenersSouth Zone Dr Krishna Mohan RWest Zone Dr Rajendra C DevNorth Zone Dr Ashwani Kumar KamdarEast Zone Dr Santanu DebCentral Zone Dr Paka R Rajender

Contributors• Dr Barnali Bhattacharya• Dr Basavaraj• Dr Dhiren Gupta• Dr Ira Shah• Dr Indu Khosla• Dr Gautam Ghosh• Dr NC Gowrisankar• Dr Jagdish Chinnappa• Dr Jagdish Dhekne• Dr Jeeson Unni• Dr E Mahender• Dr Prabhakar murthy

• Dr Srinivas Gunda• Dr Subba Rao SD • Dr Sumanth Amperayani• Dr Sushil K Kabra• Dr Subramanya NK• Dr Salim A Khatib• Dr Tanu Singhal• Dr Thangavelu S• Dr Upendra K• Dr Vijay Yewale• Dr Vineet Sehgal

• Dr Pankaj Vaidya• Dr Pallab Chatterjee• Dr Pritish Nagar • Dr Palaniraman R• Dr P Ramachandran• Dr Sanjay Natu• Dr Sanjay Bafna• Dr Somu Sivabalan• Dr Sharath Balaji• Dr Shishir Modak• Dr Shivakumar• Dr Srikanta JT

Recurrent Respiratory Symptoms

Discuss

Differentials

Recurrent Respiratory Symptoms

• Which respiratory symptoms commonly recur?

• At what age are they common ?

• What is the meaning of increased frequency ?

Symptoms and age

• Symptoms?

• Cough – Acute onset/chronic

• Snoring and Nasal symptoms

• Noisy breathing

• Breathlessness & Wheeze

• Usually in Preschool and school going age

What is increased frequency?

• Varies depending on the symptom and condition

• Recurrent respiratory tract infections (RRTI) are defined as acute respiratory infections occurring 8 episodes per year if age < 3 years and or 6episodes per year if age>or=3 years (Principi et al., 2003).

Case Scenario 1

• A 3 year old master D weighing 12 kg presents with c/o fever,

cough and cold 3 times in the last 2 months

• Subsides within 5-6 days after symptomatic medications

• Poor appetite and disturbed sleep during episodes

• Active and well in between

• Examination Normal

Points to Note

• Normal child with normal frequency of symptoms

• Anxious parents• Normal growth and

development• Interval normal• Brief disturbances of eating,

sleeping and activity• No red flags

• Counselling • What is normal?• Why?• Tonics wont help• Immune-stimulants wont work• Focus on food, fluids; exercise

and sleep• Discourage antibiotics and

cough syrups

URIs• Preschool & school children, Avg. 6 - 8 cold/year

• Cold symptoms last 10 - 14 days

• Cough (up to 2 - 3 wks. post viral URI)

• Fever, if present, generally lasts only 24 - 48 hours

• Healthy children may exhibit cold symptoms from viral URIs

• 60 - 112 days annually

TIME COURSE OF AN EPISODE OF VIRAL FEVER

Case Scenario - 2

• 3 year old master G c/o 8 episodes of fever, cough & cold – since

last 6 months

• Fever usually lasts for 3 days with running nose - watery/mucoid

• Cough not disturbing physical activity & sleep

• Similar episodes once/ twice in a month in the past

• Recently joined in kindergarten

• No family h/o atopy

On Examination

• Growth and development normal

• ENT

• nose - coryza+, post nasal drip+

• tonsils - normal

• Ear drums - normal

• Systemic examination - normal (chest clear)

Points to Note• Normal child with Increased Frequency Of Symptoms

• Normal Growth and Development

• Interval normal

• Brief disturbances of eating, sleeping and activity

• No Red Flags

but Frequency more than normal for age

Factors that can Increase Frequency ofRespiratory INFECTIONs in children

• Malnutrition • LACK OF BREAST FEEDING• Allergies• CONGENITAL ANAMOLIES• Day care, or Sibling in day care • Vitamin D deficiency

• Iron deficiency• Passive

smoke(biomass/tobacco)• Outdoor air pollution• Exposure to adult with

chronic respiratory infections

Case Scenario - 3• 4 year master F c/o frequent cough, cold• Cough is dry - More at night, with variable periods of cough free

intervals• Rubs his nose & sneezes often with persistence of nasal

symptoms• Episodes seldom associated with fever • No snoring or mouth breathing• No h/o of wheezing• Father known asthmatic

On Examination

• Growth – normal • Development – normal • Systemic evidence of atopic dermatitis• ENT

• Ear - erythema but no bulge• Nasal congestion with clear fluid• Throat - congested

Points to Note• Child With Increased Frequency Of Symptoms At One or more

contiguous anatomical Site•Nasal•Pharyngotonsillar•Ear•Laryngeal•Tracheobronchial

• Temporary Stuttering of Growth and Development• More significant disturbances of appetite, sleep and activity• Occasional Red Flags That Need To Be Elicited• Discrete Syndromes

Allergic Rhinitis (AR)

Diagnosis

• Purely based on clinical grounds• 2 or more of the following symptoms for > 1 h on most days

• watery anterior rhinorrhoea• sneezing, especially paroxysmal• nasal obstruction• nasal pruritus• conjunctivitis

+-

Allergic salute Transverse nasal crease

Allergic SaluteTransverse Nasal Crease

Denie-Morgan Lines

Allergic Shiners

Other Causes of Recurrent / Persistent Rhinitis

• Vasomotor rhinitis• Viral infection• Obstructive causes• Adenoid hyperplasia• Foreign body

• Deviated septum• Nasal polyps• Neoplasm• Medications

Case Scenario - 4

• 7 year old boy c/o recurrent cough, cold & fever (103-1040 F)

• Thick purulent nasal discharge

• Cough more on lying down posture

• Persistent Snoring worsening during episodes with gasping

during sleep

On Examination• Growth weight - 26 kg, Height - 119 cm

• Development - normal

• Head to toe examination - adenoidal facies mild retrognathia

• ENT

• Nose - Thick nasal discharge bilaterally, diminished airflow

across nares

• Ear - Bilateral OME

• VIDEO

Recurrent Sinusitis with

Upper Airway Obstruction

Snore . . . Common Causes

• Adenotonsillar hypertrophy• Overweight / obesity• Nasal congestion from colds, flu

or allergies• Nasal trauma / Deviated nasal

septum / choanal stenosis

• Facial anomaly - small or posteriorly placed jaw or a flattened midfacial profile

• Throat - cleft palate • Neuromuscular problems -

cerebral palsy, Duchene muscular dystrophy

• Large tongue - Down syndrome, hypothyroidism

Obstructive Sleep Apnea Syndrome (OSAS)

• OSAS is a “disorder of breathing during sleep

characterized by prolonged partial upper airway

obstruction and/or intermittent complete obstruction

(obstructive apnea) that disrupts normal ventilation

during sleep and normal sleep patterns”

ASK

DOES THE CHILD HAVE SOUND SLEEP OR

SOUND WHILE SLEEPING?

OSAS

Diagnosis• CLINICAL – Ask for night

symptoms, morning and daytime symptoms

• CAREFUL EVALUATION OF height and weight, face, neck, nose and mouth, chest and back, cardiovascular system

• XRAY NECK LEFT LATERAL

• POLYSOMNOGRAPHYY

Treatment• Medical

• Sleep hygiene, obesity treatment & rhinitis

• Surgical

• Adenotonsillectomy cures OSAS in 70 -80% of children with

adenotonsillar hypertrophy*

• Craniofacial abnormalities correction

• Non invasive ventilation

• Tracheostomy

Case Scenario – 5

• 7 months old with recurrent episodes of noisy breathing

• Increasing intensity with cold

• In between colds child has minimal noisy breathing

• No admissions so far

• Child thriving well

On Examination

• Growth - normal • Development - normal

• Head to toe - suprasternal retractions +• Systemic examination - inspiratory stridor

ASK

• IF THE NOISE IS MORE THAN THE COUGH –CONSIDER MALACIA SYNDROMES

Malacia – SyndromesWorsening with Viral Infections

Malacia Syndromes - Laryngomalacia• Common dynamic

abnormality of the supra-glottic area

• Presents with stridor in the first few days of life

• Usually mild and recovers in the first 1-2 years of life

Tracheomalacia• Primary or secondary defect in

tracheal cartilage• Brassy cough, Expiratory

Stridor and choking spells• Associated with vascular rings

and Tracheo-esophageal fistula• May have concomitant

bronchomalacia and Laryngomalacia

• Diagnosed by Bronchoscopy

Bronchomalacia

• Noisy breathing and ‘Wheeze’ in

early infancy, usually worse

with colds. No response to anti-

asthma or GERD treatment

• Monophonic wheeze in central

lung fields on examination

Case Scenario - 6

• 2 year old master A presented with c/o recurrent cough more during feeding (liquid feed) with nasal regurgitation of most feed since birth

• Also has had 6 episodes of AOM with recurrent LRTI with wheeze

• Weight trend

Birth

3 kgs

6 mths

5 kgs

1 yr

7 kgs

2yrs

8 kgs

On Examination• Growth and development – failure to thrive with

developmental delay• ENT

• OME bilaterally• Palate not moving well on crying• Look for evidence of submucosal cleft palate (bifid uvula)

• Systemic Evaluation• Hypotonia • Few scattered wheeze and crackles

Investigations

• Empirical anti reflux measures given• Tried ICS - NO benefit• Barium Swallow Normal study - No TEF/ GERD• Echo normal

Points to Note

• Child With Increased Frequency Of Symptoms at Multiple Anatomical Sites

• Significant effect on growth and development• Clear Red Flags• Needs Urgent Attention

VELO-PHARYNGEAL INCOMPETENCE

Aspiration syndromeVelo - Pharyngeal Incompetence

Aspiration syndrome secondary to Neuromuscular abnormalities

Case Scenario – 7

• 8 month old infant with c/o recurrent fever, moist cough and wheezing - since 1 month of age

• Multiple hospitalizations and clinic visits• Treated with antibiotics/nebulization• On examination

• Weight trend – birth (4kg) current weight (5kg)• Clubbing present with hyper-inflated chest+, Harrison sulci+• Chest – bilateral coarse crackles+

Comments?

• Recurrent and/or persisting moist cough

• Intermittent febrile episodes

• Need of antibiotics

• Clubbing

• Failure to thrive

Mucociliary Dysfunction Cystic Fibrosis

Case Scenario - 8• 13 year old adolescent admitted with c/o high grade fever, cough

and breathlessness since last 3 days

• Admitted 2 month back with similar complaints

• No significant past history of atopy or wheeze

• On examination

• Signs suggestive of left lower lobe consolidation

X-Rays

Approach

• Clinical or Radiological or both

• Recurrent / Persistent

• Single or multiple lobes• Pulmonary alone or with extrapulmonary involvement

• Associated with red flag signs

Recurrent Pneumonia

• Two episodes within same year

• 3 or more episodes over any period of time• Complete resolution of clinical & radiological findings between

episodes

Recurrent Pneumonia

Unilobar• Congenital airway anomaly

Cardiovascular anomaly• Retained foreign body• Mediastinal adenopathy• Right middle lobe syndrome• Tuberculosis

Multilobar• Recurrent aspiration• GERD• Immunodeficiency• Cystic fibrosis/ PCD

Abnormal Anatomy (Structural) / Abnormal Physiology (Functional/ Mucociliary)

Case Scenario – 8

• History continued

• Twice had discharging ears

• Several episodes of diarrhea

• Incision & drainage - 4 times (Abscess in multiple sites)

Clues to Suspect Immunodeficiency

• S P U R• Severe infection• Persistent infection & failure of expected recovery• Unusual organisms, sites• Recurrent infection

• Along with• Family history of unexplained death• Failure to Thrive

Conclusion

Normal Child, Anxious Parents, Counselling

Child With Clear Anatomical Recurrence, Sinusitis, Otitis,

Bronchitis, Asthma, Adenoiditis, Tonsillitis

Normal Child, Increased Frequency Look for Triggers

(Environmental or Nutritional)

Persistently ill Child with Exacerbations, Multiple

Anatomical Sites, Disturbance in Growth & Development, Red

Flag Signs

Recurrent

What are Red flag signs in Respiratory Disease?

Red Flags in Respiratory Complaints

• Failure to thrive (FTT) • Clubbing/Cyanosis• Low saturation on pulse oximetry• Symptoms from early infancy• Persisting moist or productive cough• Feeding difficulties, choking

Red Flags in Respiratory Complaints

• Persisting focal auscultatory findings• Hemoptysis• Chronic / exertional dyspnoea• Multisystem involvement - Immune deficiency• Neuromuscular abnormality & Developmental

issues

RECURRENT RESPIRATORY SYMPTOMS

• Recognise the pattern • Key questions• Age • Pattern of illness• Wellness interval• Key symptoms• Environment

We express our Gratitude toLupin Laboratories Respiratory Division

for making this possible