Pediatric Respiratory Disorders

TOPIC LECTURE
OUTLINE
OUTLINE

Lower Respiratory Tract Infections

- Bronchitis
- Bronchiolitis
- Pneumonia
Non-infectious disorders
foreign bodies
atelectasis
Asthma
 LOWER RESPIRATORY TRACT
INFECTIONS

BRONCHITIS
BRONCHIOLITIS
PNEUMONIA
 ACUTE BRONCHITIS
Inflammation of the bronchial respiratory mucosa
leading to productive cough.
 ACUTE BRONCHITIS

Etiology: A)Viral
B) Bacterial (Bordetella pertussis,
Mycoplasma pneumoniae, and
Chlamydia pneumoniae)

Diagnosis: Clinical

S/S: Productive cough, rarely fever or

tachypnea
 TREATMENT

A) Symptomatic

B) If cough persists for more than 10 days:

Azithromycin x 5 days
OR
Clarithromycin x 7 days
COMPLICATIONS
chronic bronchitis,
pneumonia,
asthma,
bronchiectasis
 BRONCHIOLITIS

viral disease ( RSV >50% )

more common in boys, in those who have not been
breast-fed, and in those who live in crowded
conditions.
Incidence: Children < 2 years old
80% of patients < 1 year old
Peak age: 6 months
 BRONCHIOLITIS:
PATHOPHYSIOLOGY
bronchiolar obstruction with edema, mucus, and
cellular debris and air trapping

Resistance in the small air passages during both

inspiration and exhalation
 BRONCHIOLITIS:
SIGNS/SYMPTOMS

Recent upper respiratory

infection exposure
Gradual onset of respiratory
distress
Expiratory wheezing
Extreme tachypnea (60 -
100+/min)
Cyanosis
 BRONCHIOLITIS

DIAGNOSIS
CXR
HYPERINFLATION, INCREASED LUCENCY AND INCREASED
BRONCHOVASCULAR MARKINGS AND MILD INFILTRATES
PULSE OXIMETRY
NASOPHARYNGEAL SWABS (VIRAL CULTURE)
VIRAL ANTIBODY TITERS
A chest X-ray demonstrating lung hyperinflation with a
flattened diaphragm and bilateral atelectasis in the right
apical and left basal regions in a 16-day-old infant with
severe bronchiolitis
 BRONCHIOLITIS: MANAGEMENT

Humidified oxygen
bronchodilators
Anticipate need to intubate, assist ventilations
 ASTHMA BRONCHIOLITIS
Age >2 years old <2 years old
Fever Normal temp positive
Family history positive Negative
Hx of Allergy Positive Negative
Response to positive negative
Epinephrine
 PNEUMONIA

inflammation of the parenchyma of the lungs

 PNEUMONIA
most cases of pneumonia are INFECTIOUS caused
by microorganisms (viral and bacterial)
NON-INFECTIOUS causes include aspiration of food
or gastric acid, foreign bodies, hydrocarbons, and
lipoid substances, hypersensitivity reactions, and
drug- or radiation-induced pneumonitis.
 PNEUMONIA

3 wks 4yrs:
Streptococcus
pneumoniae
(pneumococcu
s)

5 yrs and older:

Mycoplasma
pneumoniae
and Chlamydia
 Recurrent pneumonia is defined as 2 or more
episodes in a single year or 3 or more episodes ever,
with radiographic clearing between occurrences.
An underlying disorder should be considered if a
child experiences recurrent pneumonia.
 CLINICAL SYMPTOMS OF
PNEUMONIA
Triad of fever,
cough and
tachypnea
Tachypnea - most
consistent clinical
manifestation of
pneumonia
PE: crackles,
rhonchi,
decreased
breath sounds
 DIAGNOSIS

An infiltrate on
chest radiograph
supports the
diagnosis of
pneumonia
 VIRAL PNEUMONIA

hyperinflation
bilateral interstitial
infiltrates
peri-bronchial
cuffing
BACTERIAL PNEUMONIA -
CONSOLIDATION
 DIAGNOSIS -PNEUMONIA
Definitive diagnosis - isolation of
microorganism
blood culture is positive only in 10-30% of
cases
sputum culture - no clinical use
 TREATMENT
Antibiotics
Under 5 yrs
First line treatment :- amoxicillin
Alternatives : coamoxiclav, cefaclor,(for
typical) macrolides (for
atypical)
 TREATMENT
For school-aged children and in children in whom
infection with M. pneumoniae or C. pneumoniae : a
macrolide antibiotic such as
azithromycin

In adolescents: a respiratory fluoroquinolone

(levofloxacin) may be considered as an
alternative
 COMPLICATIONS OF PNEUMONIA
Due to direct spread of bacterial infection within the
thoracic cavity
Pleural effusion
Empyema
Lung abscess

S. aureus , S. pneumonia, S. pyogenes - most

common causes of parapneumonic effusions
and of empyema
 RARE COMPLICATIONS OF
PNEUMONIA

Meningitis, suppurative arthritis, and osteomyelitis

are rare complications of hematologic spread of
pneumococcal or H. influenzae type b infection.
 PREVENTION -LRTI

It is achieved with pneumococcal vaccine and

influenza vaccine
Stop indoor smoking. Smoking at home or school is
a major risk factor.
Zinc supplementation reduces the incidence of
pneumonia by over 40% in malnourished children.
NON-INFECTIOUS
RESPIRATORY
PROBLEMS
 FOREIGN BODIES OF THE AIRWAY

Most victims: older infants and toddlers

Children <3 yr of age account for 73% of cases.
most serious complication: complete
obstruction of the airway
FOREIGN BODIES OF THE AIRWAY
NOSE
Children introduce foreign objects into the nose ( nuts,
beads, erasers, crayons, seeds)
Most common: nuts
Foreign objects irritate the nasal mucosa swelling
obstruction
Infected mucosa foul purulent discharge
Dx: anterior rhinoscopy
 FAUCIAL TONSILS

Fishbones may get stuck

Can be removed by forceps
 LARYNX

If radio-opaque: X ray of the neck

If radiolucent: direct laryngoscopy
Management should be immediate, otherwise
swelling of laryngeal mucosa complete
obstruction and death
 TRACHEA

s/s similar to those of laryngeal foreign body

Findings: audible slap and palpable thud due to a
momentary expiratory impaction at the subglottic
level
If radio-opaque: X ray
If radiolucent: bronchoscopy
 BRONCHI

Most lodge in a right bronchus 58% of cases

s/s similar to that of laryngeal or tracheal foreign
body
May present with respiratory distress
May result to pneumonia
 FBAO: SIGNS/SYMPTOMS

Suspect in any previously well,

afebrile child with sudden onset
of:
Respiratory distress
Choking
Coughing
Stridor
Wheezing
 FOREIGN BODY AIRWAY
OBSTRUCTION
High clinical index of suspicion
History is the most important factor in determining
the need for bronchoscopy.
RX: prompt removal
Heimlichs maneuver
Infant: 5 back blows/5 chest thrusts
Child: Abdominal thrusts
 HYDROCARBON POSIONING

Due to aspiration of kerosene

Occurs frequently among Filipino children
 HYDROCARBON POISONING

May involve CNS, heart, kidney, GIT, but the most

frequent and most serious changes occur in the
Lungs
 HYDROCARBON PNEUMONIA

Pathology: necrosis of lung tissues

Signs and symptoms: vomiting following
ingestion
rapid progression of respiratory distress, hemoptysis and
pulmonary edema
variable findings
 HYDROCARBON PNEUMONIA

Diagnosis: CXR may show punctate, mottled

densities suggestive of pneumonitis or
atelectasis
Management: NO emetics!!!
if big amount is ingested gastric
lavage
Antibiotics
 ATELECTASIS

the incomplete expansion or complete collapse of

a segment, lobe or lobes of the lung
Can be congenital or acquired (more common)
 ACQUIRED ATELECTASIS
Commonly seen as a post-operative complication
in cases involving the thorax and upper abdomen
Blocked airways caused by mucus plugs, foreign
bodies, tumor masses, tissue scarring from chronic
infection
Decreased lung expansion due to pneumothorax or
pleural effusion
 SIGNS AND SYMPTOMS

PE: limitation of chest excursion, decreased

breath sound intensity, and coarse crackles. Breath
sounds are decreased or absent over
extensive atelectatic areas.
If the obstruction is removed, the symptoms
disappear rapidly
 DIAGNOSIS

Based on Chest X-
ray
90% of cases in
children involve the
upper lobes
63% involve the right
upper lobe
Treatment: directed
towards the
etiology
 ATELECTASIS

Complications: permanent damage of the

bronchus distal to the obstruction, fibrosis and
bronchiectasis
 BRONCHIECTASIS

Abnormal dilatation, distortion and destruction of

the cartilaginous, muscular and elastic components
of the medium-sized bronchial tree caused by
chronic infection or inflammation
Pathology: weakness of the bronchial wall
 BRONCHIECTASIS

Usually result from necrotizing bacterial infections

(Staph, Klebsiella, B. pertussis)
Viral (adenovirus)
Associated with the initial stage of pulmonary TB
impairs clearing mechanism favoring development
of bronchiectasis
 BRONCHIECTASIS

s/s: chronic cough, increased tenacious sputum,

progressive shortness of breath, easy fatigability and
hypoxia, wheezing, crackles
Diagnosis confirmed by radiography
 BRONCHIECTASIS

suspected in patients with recurrent or persistent

pneumonia especially if the expectorate is quite
copious
- confirmed by bronchography

Treatment: antibiotic therapy and postural

drainage
 BRONCHIAL ASTHMA
reversible airway obstruction characterized by:
airway hyperreactivity
airway inflammation
 If both parents are asthmatic, the risk that their child
will have asthma is 60%
For a child with only one parent with asthma, the risk
is estimated to be about 20%.
If neither parent has asthma, the risk is 6% to 7%.
About 50% of childhood
asthma develops before
the age of 3 years, and
nearly all has developed
by the age of 7 years.
The signs and symptoms of
asthma, including chronic
cough, may be evident much
earlier than the actual
diagnosis but may be
erroneously attributed to
recurrent pneumonia.
EARLY CHILDHOOD RISK FACTORS
FOR PERSISTENT ASTHMA
Positive family history of asthma (especially
maternal)
Increased IgE levels
Atopic dermatitis
Rhinitis not associated with colds
Secondhand smoke exposure
 SOME ALLERGENS WHICH MAY
CAUSE ASTHMA
House-dust mites which live in Spittle, excrements,
carpets, mattresses and hair and fur
upholstered furniture of domestic
animals

Plant pollen

Dust of
Pharmacological
book
agents (enzymes,
depo- Food components
antibiotics, vaccines,
sitories (stabilizers, genetically
serums)
modified products)
TRIGGERS OF ASTHMA
ASTHMA: PATHOPHYSIOLOGY

Bronchospasm

Mucosal Edema Increased Mucus

Production
 CLINICAL MANIFESTATION OF
ASTHMA
cough
breathlessness
tachypnea
dyspnea
Hyperinflation
Wheezing - cardinal sign of asthma
 DIAGNOSIS

Clinical
Pulmonary function tests
peak expiratory flow meter/pulse oximtery
 ASTHMA
SILENT CHEST
EQUALS
DANGER
 LUNG FUNCTION
ASSESSMENT
The most important of them are:
1. forced expiratory volume in
second (FEV1)
2. peak expiratory flow (PEF)
PEF also can be measured with the help of individual
devices peak flow meters
FEV1 and PEF directly depend
on bronchial lumen size and
elastic properties of
surrounding lung tissue.
 FVC - is the size of the biggest breath
someone can blow out.

FEV1---the volume exhaled during the first

second of the FVC maneuver

FEF 25-75%---the forced expiratory flow

between the 25th to 75th % of your
breathing ;
reflects flow through the small
(<2 mm in diameter) airways
 MEASUREMENTS OBTAINED
FROM THE FVC CURVE

FEV1/FVC---a reduction of this ratio

from expected values is specific
for obstructive rather than
restrictive diseases
reflect a persons larger airways
 Measured Test
Normal

FVC > 80%

FEV1 > 80%

FEF25-75 > 65%

Increase in FEV1 and PEF after
inhalation of bronchodilators
(b2-agonists) of 15% and more
is specific for asthma.
CXR
 DRUG THERAPY
2 drug categories are used:
Antiinflammatory drugs
Bronchodilators
(basic)

Are divided into: 3 groups:

hormone-containing b2-agonists
(corticosteroids)
anticholinergic drugs
nonhormone-containing
(cromones, leukotriene
methylxanthines
receptor antagonists)
 BRONCHODILATORS
Anticholinergic
b2-agonists drugs

Stimulates reduce tonus

b2-adrenergic of vagus
receptors of bronchi Smooth
muscle
relaxation

inhibit phosphodiesterase
Methylxanthines