respiratory diseases in children christine t. quien-sua, md dpps dpapp pediatric pulmonology january...

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!!!