.

Ukrainian children’s morbidity in 2011

diseases of respiratory

system66,75 %

diseases

of digestive system4%

diseases

of skin and SFT5%

diseases

of eyes3%

diseases

of aers3%

diseases

of bones, musculs and connective

tissue2%

diseases of

genitourinary system2%

trauma, poisoning and oth.

3%

other

11%

www.m

oz.gov.ua/docfiles/Med_demo_situation_2010.pdf

respiratory tract

UPPER

( nose, pharynx)

MIDDLE

(larynx, trachea, bronchi)

LOWER

(bronchioles, alveoli)

APF of nose Relatively small size.

Narrow nasal passages (lower

nasal conchas are absent,

they get formed by the age of

4 years).

mucous membrane

abundantly vascularised.

cavernous submucosal tissue

develops by the age of 8-9

years.

nasal

obstruction

impediment

during suckling,

dyspnea.

hyperaemia and edema

possibility to suckle

rare nasal

hemorrhage

paranasal sinuses. 1 — frontal; 2 — ethmoidal; 3 —

sphenoidal; 4 — maxillary

sinuses new

born

2 years 6 years 7

years

12

years

15

years

20

years

maxillary undeve

loped

get

formed

frontal - start to

develop

get

formed

sphenoidal undeve

loped

get

formed

ethmoidal - start to

develop

get

formed

Functions of paranasal sinuses Decrease of relative weight but keep volume of skull front

section, especially facial bones – place of fastening for

facial muscles.

Increase of vocal resonance

Insuring of shock-resistant buffer in case of trauma

isolation of sensible structures (roots of teeth, eyeballs)

from fast temperature fluctuation in nasal cavity during

inhalation and exhalation.

Moistening, cleaning and warming of air due to slow

airflow into the sinuses.

provoke sneezing.

Nasolacrimal duct is short with

underdeveloped valves that

simplify infection of

conjunctival sac from nasal

cavity.

APF of pharynxnarrow and more

vertical

location of Eustachian tube in adults (above) and children

(short, wide, straight, horizontal)

Pharyngeal Waldeyer’s lymphoid ringmaximal development in 5-6 years

1 — lingual tonsil;

2 — palatine tonsils;

3 — pharyngeal

tonsil;

4 — tonsils of torus

tubaris;

5 — lymphatic

follicles in mucous

membrane of back of

the throat.

normal adenoids enlarged adenoids

Fauces

APF of larynx After birth the form is funnel-shaped,

later on – cylindrical.

Located higher, it’s relatively longer

and narrow.

Mucous membrane is very gentle,

soft, considerably vascularised.

Rich in lymphoid tissue.

Muscles of vocal fissure get tired

easily

Vocal fissure is relatively narrow till

the age of 6-7, vocal cords are short

disturbance

of respiration

up to

stenosis

hoarseness

high pitched

voice

Th 6

С 7

С 4

Th 3-4

4 sm

12 sm

APF of trachea

The walls are soft and get palpated easily.

The mucous membrane is soft, abundantly

vascularised and relatively dry.

APF of bronchi

Narrow and soft.

Muscular and elastic fibers are poorly

developed (by the age of 7 years).

The mucous membrane has rich

vascularization, covered with ciliated

epithelium, which carries out mucociliary

clearance.

APF of lungs Breathing surface is

relatively large.

Relatively big lungs occupy

more place into the chest,

they are squeezed into the

ribs, intercostal space are

smoothed out. The chest is

always in state of inhalation.

The ribs are almost

perpendicular to spine.

In children of 1 year of life upper

lobes of left lung is poorly

developed; upper and middle lobs

of right lung are almost identical

with size. The sizes of lobs

corresponds to adult sizes by the

age of 2 years.

Interlobar fissures are

undeveloped

absence of interlobar pleurisy

segments are well

delimited (sometimes

2,4,5,6 segments in the

left lung are fully

delimited)

segmental pneumonia

more often inflamation

locates in 4, 5, 6

segments of the left lung

and in 2, 10 segments of

the both lungs. 10 segments

root of lung is spacious, with a lot of blood vessels and lymph nodes

possible development ofbronchoadenitis.

elastica is undeveloped

atelectasis

a lot of interstitial connective tissue

are around alveoli

frequent interstitial pneumonia

in children of 1 year of life.

functional particularities of breathing

frequent and superficial

respiration rate of newborn = 40-60 per

1 min, 1 year = 30-35, 5 years = 25, 10

years = 20, more than 10 years = 18-

16 per 1 min.

respiration rate is considerably unsteady

(because of psychic excitement,

physical activity, changing of body and

environment temperature)

physiological arrhythmia and apnea (first 3 months of life)

diaphragmatic type of breathing (first 6 months of life)

small

respiratory

volume,

considerable

resilience

immaturity of

respiratory center.

weakness of

respiratory

muscles, horizontal

disposition of ribs.

The lung buds form during the 4th week

Initially appear as the respiratory diverticulum, which is a ventral

outgrowth of foregut endoderm

Splitting of foregut into esophagus and trachea

Tracheo-esophageal ridges: longitudinal ridges that eventually fuse

to separate trachea from esophagus.

Tracheo-esophageal fistulas /

esophageal atresia

Incomplete separation and/or atresia of trachea and esophagus (B on

right shows esophageal atresia)

Differentiation of pleural membranes

The lung buds “punch” into the visceral mesoderm. The mesoderm,

which covers the outside of the lung, develops into the visceral

pleura. The somatic mesoderm, covering the body wall from the

inside, becomes the parietal pleura. The space between is the

pleural cavity.

Separating the abdominal and thoracic cavities: development of the septum transversum and diaphragm

Extension of the

septum transversum

partially divides

abdominal and

thoracic cavitiesGrows in a roughly transverse

plane from front to back

Angled downward such that

front of septum is at about T7,

back edge is at about T12

Congenital diaphragmatic hernias

Relatively common (1/2000 births)

Hiatal hernias are most frequent,

but effects are rather minor due to

small size of defect

Hernias due to failure of one or both

pleurpericardial membranes to

close off pericardioperitoneal canals

have much more significant clinical

impact because herniated

abdominal contents interfere with

lung development.

80-90% of hernias with clinical

impact are on the left side. Large

defects have high mortality due to

extent of lung hypoplasia and

dysfunction.

First three branching events are

stereotyped:

After the initial bifurcation into

two primary bronchi, two buds, or

secondary bronchi, form on the

left and three on the right

predicting the five lobes of the

adult human lung. Ten tertiary

(segmental) bronchi form in the

right and left lungs - establishing

the brochopulmonary segments

of the adult human lung.

Initial Patterning of the Lung:

Development of the human lung

7 trachea; 1 Left main bronchus; 6 right main bronchus; others lobes

Agenesis of the lungs:

Can occur bilaterally or unilaterally. Unilateral lung agenesis is compatible with

live as remaining side hyperexpands and compensates.

Lung aplasia:

Is defined as unilateral absence of the lung with preservation of main bronchus

remnant at the tracheal bifurcation.

Lung hypoplasia:

Often caused by congenital diaphragmatic hernias or congenital heart disease.

Characterized by reduced lung volume.

Pseudoglandular

Period (5-17

weeks):

By 17 weeks, all major

elements have formed,

except those involved with

gas exchange (fetuses

unable to survive if born at

this stage).

Canalicular Period

(16-25 weeks):

Bronchi, terminal bronchioles

become larger, lung tissue

becomes highly vascular.

Alveolar ducts form by week

24. By end, some terminal

sacs have formed so

respiration is possible (small

chance of survival at this

stage).

Terminal Sac

Period (24 weeks

to birth):

Many more terminal sacs

develop, their epithelium

becomes very thin and

capillaries bulge into the

developing alveoli.

Blood-air barrier

becomes well-developed.

(By 26-28 wks, 1000 gr

fetus has a sufficient # of

sacs and surfactant to

survive.)

Alveolar Period (late

fetal period to age 8):

Alveoli-like structures are

present by 32 weeks.

Epithelial lining of sacs

attenuate to extremely thin

squamous epithelia, capable

of gas exchange. 95% of

characteristic, mature alveoli

develop after birth.

Stages of maturation of the lungs

Canalicular

Period:

(16th-26th week)

Terminal Sac Period:

(24th weeks to birth)

Type I squamous cells

Alveolar Period:

(late fetal thru childhood,

Type II, surfactant-

producing cells)

Development of lung tissue involved in air exchange

At birth:

Alveoli continue to mature after birth. Growth of lungs

after birth due primarily to increase of respiratory

bronchioles and alveoli. Only 1/6 of adult alveoli present

at birth.

Lungs are fluid filled; fluid squeezed out and into

lymphatics and blood vessels, expelled via trachea at

delivery.

Surfactant remains on surface, lowers air/blood tension.

Surfactant deficiency

Respiratory Distress Syndrome/Hyaline Membrane DiseaseThis disease affects 2% of live

newborn infants, with

prematurely born being most

susceptible. 30% of all

neonatal disease results from

HMD or its complications.

The reason of syndrome is the immaturity or damage of

surpfactant. The basic signs –infringements of function of

respiration – tahypnea, the mixed dyspnea, cyanosis and

periodic types of respiration.

Respiratory Distress Syndrome

Respiratory Distress Syndrome

The foam on the lips innewborn and infants isan equivalent of cough.

Positional Nasal Deformity

Positional Nasal Deformity

An occasional finding on physical

exam is an asymmetric

appearance of the nose due to a

positional deformity. Most likely,

this results from an unfortunate

position in utero. The nares in this

case are asymmetric and slightly

flattened towards the infant's right,

even though the septum is still

centrally located.

Positional Nasal Deformity

Positional Nasal

Deformity

Viewed from below, one

can more clearly

appreciate the

asymmetry of the nares

and the angulation of the

septum.

Positional Nasal Deformity

Dislocated Nasal Septum

From this view, the

deformity is more easily

seen. The septum is not

straight. Compressing

the tip of the nose gently

can also help distinguish

this condition from a

positional problem.

Congenital Anomalies of the Larynx

Laryngomalacia (most common) – most frequent cause of stridor in infants and children

- Starts in first weeks of life, symptoms increase up to 6 months

- Symptoms: inspiration stridor, less in prone position, increased by any exertion

Airway Foreign Body

Most seen in children age 3-4 years

Clinical: sudden onset of respiratory distress, choking, cough, hoarseness, shortness of breath, wheezing (asymmetric) and decreased breath sounds (asymmetric); depends on location

Complications: obstruction, infection, mediastinitis

Diagnosis – chest x-ray

Therapy – removal by bronchoscopy

Airway Foreign Body

Сongenital stridor

•Whistling respiration – a stridor.The stridor can be congenital –anomaly of a structure of a larynxand acquired – a paralysis of vocalchords, compression of respiratorytract from outside (by tumor,enlarged lymph node, thymus)

Congenital Lung Cysts

Cysts (filled with fluid or air)

are thought to be formed by

the dilation of terminal bronchi,

probably due to irregularities in

later development. If severe,

cysts are visible on

radiographs. Highly variable

outcomes result from different

cystic conditions.

Congenital Lung Cysts Cystic fibrosis – major cause of severe chronic

lung disease and most common cause of exocrine

pancreatic deficiency in children

Clinical presentation from RT

-Cough, purulent mucus – early in first year, extensive

bronchiolitis, then pulmonary function test

abnormalities, dyspnea; finally – cor pulmonale,

respiratory failure, and death; high risk for

pneumothorax

-Examination: hyper-resonance, rales, expiratory

wheezing, clubbing, cyanosis (late)

first breathhydraulic pressure + natural resistance

increasing of excitability of respiratory center’s neurons

activation of reticular formation

hypoxia + afferent impulses

A comparison of the

first breath (lower loop)

with a breath at one day

of age (top loop). Note

that before the first

breath the lungs

contain no air at all. At

the end of the breath,

functional residual

capacity is immediately

achieved; about 15 ml

of air remains. The first

breath takes in about 45

ml of air. 24 hours later,

FRC is about 90 ml, far

less pressure is

generated, and only

about 15 ml of air is

inhaled.