upper respiratory tract lower respiratory tract cricoid cartilage

Upper respiratory tract

Lower respiratory tract

Cricoid cartilage

Common diseases

Upper respiratory tract:

♥ Influenza

♥ Tonsillitis

♥ laryngitis

Lower respiratory tract:

♥ bronchitis

♥ Asthma

♥ Pneumonia

Ventilation and perfusion

Alveolar space

70% 100%

O2 CO2

Ventilation and perfusion

Pathophysiology

toxin

Ventilation disorder

Mucous inflammatoryexudation

Tract stenosis andobstruction

Microorganisms

Mucous congestionand edema

EmphysemaPulmonary atelectasis

Gas Exchange disorder

Respiratory failureCirculatory disorder

Neural disorderDigestive disorder

HypoxemiaCO2 elimination disorder

toxemia

According to WHO’s report:

Among all the pediatric patients, 90% suffered

from infectious diseases;

Among all these patients with infectious

diseases, 90% are diagnosed as URI.

Among all these URI patients, 90% are infected

by virus.

Pneumonia

Pneumonia is termed as infections of the

alveoli caused by microorganisms or other

noninfectious factors.

Pneumonia still carries a high mortality rate

in infants who are not treated promptly and

properly.

There are many different causes of pneumonia in

children. The most common causes are germs.

Viruses are usually the cause in 90% of pneumonia

infants and young children. Children with a viral

pneumonia may have a better chance of developing

a bacterial pneumonia, too.

Pneumonia can also be caused by foreign

material such as food or stomach acid, especially in

newborn and infants. These materials are aspirated

(inhaled) into the lungs.

Common causes

Newborns group B Streptococcus

respiratory syncytial virus

Infants

Viruses

parainfluenza viruses, influenza virus, adenovirus

Atypical organisms

Chlamydia trachomatis, Pneumocystis carinii

Bacterial

B. pertussis, Streptococcus pneumoniae, Haemo-

philus influenzae

Common causes

Young children

Viruses

parainfluenza viruses, influenza virus, adenovirus

Atypical organisms

Mycoplasma pneumoniae

Bacterial

Pneumococcus, mycobaterial tuberculosis

Older children and adolescents

Atypical organisms

Mycoplasma pneumoniae, Chlamydia

trachomatis

Bacterial

Pneumococcus, B. pertussis, mycobaterial

tuberculosis

Bacterial pneumonia

Viral pneumonia

Mycoplasmal pneumonia

Common Signs and symptoms

Cough

Breathing pattern

Cyanosis

Respiratory Sound

Cough

A cough is a voluntary or involuntary

explosive expiration. The cough reflex is initiated

by the stimulation of subepithelial

mechanoreceptors in the trachea,

bronchi and interstitium.

Cough

Paroxysm: A series of coughs that is difficult to stop. It is due

to pertussis, viral infection and asthma, etc. During paroxysm

of coughing, headache, vomitting, conjuctival hemorrhage may

be induced by the increased intracranial pressure.

An acute cough may be benefit to eliminate the obstruction or

facilitate mucociliary clearance when foreign bodies or excess

mucus is present. A chronic cough may be harmful to cause

complications, such as chest pain.

Breathing pattern

Normal breath breath with Severe pneumonia

Cyanosis

When maximal respiratory efforts cannot provide

sufficient ventilation to saturate the blood fully and

the amount of unoxygenated Hb exceeds 50g/L, the

children will appear cyanotic.

Respiratory sounds

Breath sounds are influenced by the depth of

breathing, velocity of the air flow, position of the

patients and the fluid in the air space.

The pitch of breath sounds depends on the size of

the orifices or the diameter of the airway: the smaller

the orifice or the airway, the higher the pitch.

Symptoms of different pneumonia

Viral pneumonia

The respiratory syncytial virus is the most common agent.

It is often accompanied by a skin rash and unresponsive to

antibiotics.

Adenovirus may produce viral pneumonia in children and

young adults. It more commonly causes upper respiratory

tract disease with prominent rhinitis.

RSV Pneumonia

Respiratory syncytial virus is the major respiratory

pathogen of young children, causing lower respiratory

tract disease in infants. Infection may occur at any

time but is least frequent in the summer, accounting

for 20 to 25% of hospital admissions for pneumonia of

young infants and children.

RSV Pneumonia

lower respiratory diseases, primarily, pneumonia,

bronchiolitis and tracheobronchitis occurs in 25-40%

of cases

onset is gradual with rhinorrhoea, low-grade fever,

cough, wheezing and mild systemic symptoms

tachypnoea, dyspnoea, frank hypoxia, cyanosis and

apnoea may develop in severe cases

wheezing and crackles may be heard on auscultation

there may be an accompanying skin rash

Bacterial Pneumonia

usually a history of preceding upper respiratory tract viral

infection.

more common in winter months with sudden onset

marked fever; febrile convulsions in preschool children

cough - initially dry but replaced by a productive cough with

rusty-coloured sputum after 24 - 48 hours

breathing - rapid and shallow; diminished movement on the

affected side

may be signs of consolidation and a friction rub

pneumococcal pneumonia

Bacterial Pneumonia

usually a history of preceding upper respiratory tract viral

infection.

more common in winter months with sudden onset

marked fever; febrile convulsions in preschool children

cough - initially dry but replaced by a productive cough with

rusty-coloured sputum after 24 - 48 hours

breathing - rapid and shallow; diminished movement on the

affected side

may be signs of consolidation and a friction rub

staphylococcal pneumonia

Mycoplasmal pneumonia

peak rate of infection in autumn and early winter

initial influenza-like disease with headache, fever,

malaise, myalgia, diarrhea and fatigue - often

develop several days before the onset of

respiratory problems; the malaise and fatigue may

persist for long after the acute illness

wide variety of respiratory and non-respiratory

complications

cough - initially dry and often insignificant; usually

becomes productive with a mucoid and purulent

sputum; often paroxysmal, disturbing sleep; may be

absent in one-third of cases

isolated crackles or areas of wheezing may be

heard over one of the lower lobes

subsegmental atelectasis and small effusions often

detectable in the absence of prominent chest

symptoms

Radiology

Radiologic features are variable depending upon the extent

of the infection. Chest radiology

may show hyperexpansion,

peribronchial thickening, and

infiltrates ranging from diffuse

interstitial infiltrates to

segmental or lobar consolidation.

RSV pneumonia


classically, shows consolidation with a lobular

distribution note that radiological

changes may lag behind

the clinical course of the

disease and conversely,

radiologic features may

persist for several weeks

after being cured.


The chest radiograph often appears cavitated.

Infection starts in the

bronchi, causing areas

of patchy consolidation

in one or more lobes.

These break down to

form multiple thin walled

abscesses – pneumatocoeles

- which appear as cysts.


Chest radiology is highly variable. The most frequent pattern is one

of bronchial thickening

with areas of interstitial

infiltration and subsegmental

atelectasis involving one of

the lower lobes; sometimes,

there may be dramatic

shadowing in both lower lobes.

Often there is no correlation

between radiologic appearance

and the clinical state of the patient.

Lab tests

RSV pneumonia

Diagnosis is established by

isolation of RSV from respiratory

secretions, particularly, sputum or

throat swabs. Immunologic

reactions such as ELISA are then

used to detect the virus in tissue

culture.

Techniques based on complement fixation or

neutralisation of antibody titers are more valuable

in older children and adults.

A bedside immunoassay kit is now available

which detects RSV; confirmation should be sought

with the laboratory tests detailed above.

Lab tests


white cells - raised; often greater than 15 x 109

per litre

ESR - raised; may exceed 100 mm in an hour

CRP - raised

Sputum examination, sputum and blood culture-

positive in 25-40% of cases, are essential in

management of a patient with pneumonia. It may

possible to demonstrate

pneumococcal antigen

in both blood and sputum.

Lab tests


sputum examination and culture

blood culture - positive in 20 - 30% of cases

full blood count

ESR

CRP

Lab tests


White cell count is usually normal but ESR may be

raised and C reactive proteins may be elevated.

a rise of specific antibody titre - occurs in most

instances, but, obviously, requires paired samples

separated by a week or more, and is therefore not

useful in the inital diagnosis

cold haemagglutination serology - present in about

50% of cases but may produce false positives in

measles, infectious mononucleosis,

adenovirus pneumonias, certain

tropical diseases and collagen

vascular disease.

Treatment is largely symptomatic. Intubation and ventilatory

assistance are given if there is severe hypoxia. Humidified

oxygen may be required if arterial oxygen tension is low.

Ribavarin, a nucleoside analogue which is active in vitro

against RSV, has been shown to relieve lower respiratory tract

illness in children. It is used by inhalation since oral

administration is associated with liver and bone marrow toxicity.

Studies have yet to be conducted in adults.

RSV pneumonia


Pneumococcal pneumonia is generally treated with

amoxycillin, ampicillin or co-amoxiclav.

For severe infections:

intravenous antibiotics e.g. ampicillin or co-amoxiclav.

Oral amoxycillin or augmentin can be used when the

pneumonia is resolving clinically and the patient is

apyrexial.

For mild-moderate infections:

amoxycillin 500mg tids for 10-14 days.

Alternative treatments in penicillin allergy include

erythromycin or cefuroxime (but note 10% cross-

sensitivity).

Prophylaxis:

pneumococcal vaccination


Antibiotic treatment should be started after blood and sputum has been taken for culture. Initial therapy is often blind.

Consult with a bacteriologist about appropriate drug treatment if in doubt:

penicillin-sensitive first choice: benzylpenicillin

alternative: erythromycin

penicillinase producing first choice: flucloxacillin

alternative: dependent on local sensitivities


Treatment is with either erythromycin or tetracycline:

erythromycin or other macrolide e.g. clarithromycin or

azithromycin:

tetracycline:

an alternative to erythromycin for the treatment of chlamydial

and mycoplasma infections

Treatment period is for a minimum of 10-14 days.

upper respiratory tract lower respiratory tract cricoid cartilage

Documents