Teaching Respiratory Diseases in Bedside Paediatrics

Dr. Pushpa Raj Sharma Professor of Child Health Institute of Medicine

Why children are brought to Kanti Childrens Hospital?

Fever Cough or difficulty in breathing. Diarrhoea/Vomiting Not feeding well Abdominal pain Rash

A child with cough or difficulty in breathing

Triage by symptoms

Triage by signs

Convulsion/drowsy Grunting Bluish spell Persistent vomiting Inability to swallow/drooling of saliva

Glasgow coma scale Stridor/chest indrawing/flaring of ale nasi Cyanosis Dehydration Epiglottitis/peritonsil ar abscess/ retropharyngeal abscess

Detailed history: Present illness

Entry questions Threading questions

Duration of symptoms Onset of symptoms Risk factors Treatments Other system involvement

Does your child can lie flat while sleeping? Which side s/he prefers to lie down? Hours, days, months. Preceding runny nose Mother smoker, biomass fuel for cooking Nebuliser Mental retardation

Detailed history: Past illness

Recurrent episodes Present since birth Same precipitating factor Drugs used Operations

IgA deficiency Congenital anomaly Asthma Salbutamol in asthma Tonsillectomy

Birth history

Antenatal infection Prematurity Low birth weight Intubation Hypothermia Jaundice

Pneumonia Immature lung Pneumonia Laryngeal stenosis Surfactant deficiency Alfpha 1 antitrypsin deficiency

Nutritional history

Formula feeding Vit A deficiency Protein deficiency Adequate calorie Inadequate calorie Cows milk Too much calorie

Asthma Pneumonia Recurrent infection Hyper catabolic state Hypoglycaemia Haemosiderosis Diminished chest expansion

Developmental history

Delayed motor milestones. Trisomy Mental retardation

Recurrent infections. IgA deficiency Aspirations

Family/social history

Over crowding Similar disease Smoker Domestic smoke Carpet worker Change of place Sleeping with coal heat

Recurrent infections Tuberculosis Cough Cough Tuberculosis/asthma Asthma CO poisoning

Inspection

Respiratory rate Pattern of breathing Triage signs Red eyes/runny nose Transverse creases in the nose Prominent maxilla Harrison's sulcus Atopic eczema

Pneumonia Acidosis Grunting etc Viral infections Allergic rhinitis Enlarged adenoids Recurrent obstructive air way disease Asthma

Palpation

Tenderness Displaced apex beat movement Cervical nodes vocal fremitus Liver Shifting trachea

Trauma Pneumo/collapse Pneumonia/effusion Lymphoma Consolidation Pneumothorax/sepsi s Effusion/collapse

Auscultation

Turbulent air flow through the respiratory tube causes vibration of its wall Sound generated by this vibration is transmitted through different media to the ear drum then to cortex Inspiration and expiration will have different quality Changes in the wall and conducting media changes the quality of sound

Types of respiratory sound

Different names
Snoring

Dry sounds

stridor
Wheeze Ronchi Breath sound

Vesicular Bronchial Vesicular with prolonged expiration

Moist sound:

Fine crepitations Coarse crepitations Plerual rub

Characteristic of moist sounds

Asses with each respiratory cycle

In respiratory tube whole inspiration and expiration In alveoli at the beginning and end of inspiration and expiration

Auscultation

Snoring Stridor Wheeze Ronchi Prolonged expiration Vesicular Bronchial

Palatal palsy Epiglottitis Asthma/foreign body Bronchiolitis Asthma Normal Consolidation/ collapse

Percussion

Tenderness Hyper resonant Dullness Displace upper border of liver dullness

Trauma/infection Pneumothorax Effusion/collapse/ consolidation Hyperinflation

Other system examination

VSD Juvenile rheumatoid arthritis Gastrooesophageal reflux Hepatosplenomegaly Failure to thrive

Recurrent pneumonia Pleural effusion Recurrent aspiration

Malignancy Cystic fibrosis