Respiratory complaints in children

1. Respiratorycomplaints in children

2. Tachypnea: • An abnormally rapid rate of breathing.

3. Bradyapnea: • An abnormally slow rate of breathing.

4. Tachycardia: • An abnormal condition in which the myocardium contract regularly but at rate greater than normal.

5. Bradycardia: • An abnormal circulatory condition in which the myocardium contract steadily but at a rate less than normal.

6. Cyanosis: • Bluish discoloration of the skin & mucous membrane caused by an excess of deoxygenated hemoglobin in the blood or a structure defect in the hemoglobin molecule.

7. Grunting: • Abnormal short audible grant like breaks in exhalation that often accompany severe chest pain. The grant occurs because the glottis briefly stops the flow of air, halting the movement of the lungs & their surrounding or supporting structures.

8. Clubbing: • Increase in the soft tissue of the distal parts of a fingers or toes in which the extremities are broadened & the nails are shiny & abnormally curved.

9. Nasal flaring: • A sign of respiratory distress, reduces the resistance to inspiratory airflow through the nose & may improve ventilation.

10. Hypoxia: • An inadequate reduce tension of cellular oxygen characterized by cyanosis, tachycardia, hypertension, peripheral vasoconstriction, dizziness & mental confusion.

11. Hypercarpia: • Greater than normal amount of carbon dioxide in the blood.

12. Acid-base balance: • A condition existing when the net rate at which the body produces acid or bases equal the net rate at which acid or bases are excreted, the result is a stable concentration of hydrogen ion in body fluid.

13. Wheeze: • A form of rhonchus common characterized by a high pitched musical quality. Its caused by a high velocity flow of air through a narrowed airway, & It’s heard both during inspiration & expiration.

14. Stridor: • An abnormal high pitched musical respiratory sound caused by an obstruction in the trachea or larynx.

15. Cough: • A rapid expulsion of air from the lungs typically in order to clear the lung airways of fluids, mucus, or material.

16. Differential diagnosis of acute stridor at different ages: • Laryngotracheobronchitis: commonly known as croup, is the most common cause of acute stridor in children, especially children aged 6 months to 2 years. • Aspiration of foreign body is common in children aged 1-2 years. • Bacterial tracheitis is relatively uncommon and mainly affects children younger than 3 years. • Retropharyngeal abscess is a complication of bacterial pharyngitis observed in children younger than 6 years . • Peritonsillar abscess. • Spasmodic croup, occurs most commonly in children aged 1-3 years. • Allergic reaction. • Epiglottitis is a medical emergency occurring most commonly in children aged 2-7 years.

17. Differential diagnosis of chronic stridor at different ages: • Laryngomalacia is the most common cause of inspiratory stridor in the neonatal period and early infancy. • Patients with subglottic stenosis can present with inspiratory or biphasic stridor. • Vocal cord dysfunction. • Laryngeal dyskinesia, exercise-induced laryngomalacia, and paradoxical vocal fold motion are other neuromuscular disorders that may be considered. • Laryngeal webs are caused by an incomplete recanalization of the laryngeal lumen during embryogenesis. • Laryngeal cysts are a less frequent cause of stridor. • Laryngeal hemangiomas (glottic or subglottic) are very rare. • Laryngeal papillomas. • Tracheomalacia. • Tracheal stenosis.

18. Croup: • Mucosal inflammation & swelling by laryngeal & tracheal infection. • Can cause life-threatening airway obstruction in young children.

19. Croup Viral croup Bacterial croup Spasmodic or recurrent haemophilus influenzae

20. Viral croup… • 95%. • The commonest is Para-influenza v. • RSV & influenza. • Affect.. 6 months_ 6 years (peak at 2 years).

21. Pathogenesis.. • laryngeotrachiaitis Mucosal inflammation & increased Secretion. Edema that cause narrowing of the trachea. Obstruction of the airway.

22. Symptoms… ( worse at night) • Barking cough. • Harsh stridor. • Hoarseness. • Fever & coryza.

23. Clinically assessment of sever upper airway obstruction.. • Sternal & subcostal recession. • Respiratory rate. • Heart rate. • Increased agitation. • Drawsiness ,tiredness , exhaustion. • Central cyanosis.

24. Management Basic manag. • Don’t examine the throat. • Reduce the pt. anxiety. • Observe the signs of hypoxia. • Urgent tracheal intubation in case of obstruction.

25. Mild croup: can managed at home. (mild obst. , stridor & chest recession disappear at rest). • Sever croup: at hospital. (sever symptom , oxygen sat. less than 93% in air). • Less than 2%: require intubation.

26. Cont. management.. • Inhalation of worm moist air. • Oral dexamethazone & nebulized steroids. • Nebulized adrenaline (transient improvement in sever obst.)

27. Spasmodic , recurrent croup • Suddenly develop braking cough , stridor at night without preceding respiratory symptoms. • Have hyper-reactive upper airway. • Some will develop other or a topic illnesses hey fever, eczema.

28. (Pseudomembranous croup) Bact. tracheitis. • Rare but dangerous. • Caused by staph aureus or h. influenza . • Clinical pict. Similar to sever viral croup + high fever ,appear toxic. • Rapidly progressive airway obst. • Copious thick secretion found with tracheal intubation.

29. Acute Epiglottitis • Definition: Inflammation of supraglottic region of the oro-pharynx (epiglottis , vallecula, arytenoids, aryepiglottic folds).

30. Causative organisms: • 1- Most commonly Hib • 2- Hemophylus parainfluenzae • 3- Strept. pneumoniae • 4- Group A streptococcus • 5- Staph. aureus

31. Frequency : Generally uncommon . • Increase incidence in areas that don't require mandatory Hib vaccine • More common in children than in adults with a ratio of 2.6:1 respectively . • But may occur at any age. • Age : In children 1 --> 6 years adults >45 with a male predominance. 3:1 M:F ratio. • However , with the introduction of Hib vaccine in infancy, there has been a 99% decrease in incidence of epiglottitis + other Hib infections.

32. Morbidity + Mortality: 1- Airway obstruction : by inflamed epiglottis that obstructs the airway also by impaired clearance of secretions. 2- difficulty intubating patients with extensive swelling. • adult mortality rate 7%. • child mortality rate < 1%.

33. Clinical picture: • is usually acute with rapidly progressive presentations. • SYMPTOMS:- 1- sore throat (95%) 2- odynophagia / dysphagia (95%) 3- muffled voice (54%) 4- dyspnea 5- usually not preceded by prodromal symptoms or coryza . There may be mild or absent cough

34. SIGNS: • Patient looks ill, toxic and irritable. • fever > 38.5 ˚C. • tachycardia and tachypnea. • soft inspiratory stridor with rapidly progressing respiratory distress causing child to lean forward and hyperextend the neck to enhance air exchange. • drooling and inability to handle secretions. • cervical lymphadenopathy. • on direct / indirect visualization of the larynx, a beefy, red, stiff and oedematous epiglottis can be seen. • N.B. Attempts to lie the child down or examine the throat with spatula or obtain swabs must not be undertaken as they can precipitate total airway obstruction and death

35. Diagnosis: • 1-Lab studies :- a- Epiglottic swab: samples for laboratory tests should not be drawn and epiglottic swab culture should not be obtained until the airway has been secured. b- Blood culture.

36. 2-Imaging studies :- a- Lateral neck soft tissue x-ray is useful to confirm diagnosis (using a criteria of 7mm thickness as being 100% specific and sensitive as the normal thickness is 3mm). b- Chest x-ray : for visualization of endotracheal tube. Radiographic evaluation is being replaced by direct visualization by pharyngoscopy c- Naso-pharygoscopsy (diagnostic method): should be done in patients who are not distressed and when DX of epiglottitis is suspected (avoid this method until airway has been secured).

37. Treatment: • A- Securing the airway: according to the degree of epiglottitis severity a-In patients with severe disease (i.e. presenting with respiratory distress ,stridor, inability to swallow, sitting erect and deterioration within 8-12 hours), securing the airway is the safest method 1- orotracheal intubaion is almost always required when there is acute airway obstruction. 2- if intubation can not be performed, cricothyroidotomy or needle-jet insufflation are the next lines of treatment. b- Patients without signs of airway compromise may be managed without immediate airway intervention by close monitoring in the ICU.

38. Cont. treatment.. • B- Administer supplemental humidified Oxygen • C- Antipyretics • D- Antibiotic therapy: after blood and epiglottic cultures have been obtained, emperic coverage for group A Streptococcus pneumoniae, S.pyogenes and H influenzae should be provided ( third degree cephalosporin or amoxicillin/clavulanic acid) e.g. Ceftriaxone, Ampicillin, Choloramphenicol • N.B1: Racemic epinephrine, steroids, sedatives and Beta agonists should be avoided. • N.B2: An anaesthesiologist and ENT specialist should be notified as soon as a possible case of emergency epiglottitis or if operative management is anticipated.

39. Prevention: • 1- Hib vaccine. • 2- close contacts of patients in whom Hib has been isolated should receive Rifampin prophylaxis.

40. Complications: 1- Pulmonary edema 2- Epiglottic abscess 3- Pneumonia 4- Meningitis 5- Cervical adenitis 6- Septic arthritis 7- Pericarditis 8- Cellulitis 9- Septic shock

41. Difference between croup and epiglottitis:

42. Cough What is cough? A forceful expiration that removes excess secretions, foreign body and infected material from the airway.

43. How does it happen? Cough may be voluntary or may be generated by reflux. Stimulation of irritant receptors in the airway mucosa: • nose, • sinus, • pharynx, IX • larynx, • trachea, X • bronchi or bronchioles. • Pleura • Pericardium and diaphragm phrenic N.

44. Mechanism of cough: • During cough, person inspires deeply to 60% to 80%of TLC. • The glottis closes and respiratory muscles contract leading to compression which greatly increases intra-thoracic pressure. • Explosive exhalation, the glottis open suddenly. • The airways are cleared by compression and high velocity exhaled gas.

45. Loss of reflex can be due to: • unresponsive nerve endings, • depression of cough center in brain stem, • laryngeal disorders(paralysis of vocal cords), • or extensive disease in peripheral airways and alveoli.) Complications: • leads to aspiration and • pneaumonia.

46. HISTORY: 1) Onset 2) Duration 3) Productive 4) Time of day 5) Aggravating and alleviating factors 6) Associated wheeze or stridor 7) Associated symptoms 8) History of exposure to respiratory illness 9) Family Hx 10) Environmental history

47. EXAMINATION: • General look • Respiratory pattern and rate, work of breathing • Inspection • Palpation • auscultation

48. Caused of acute cough: • URTI • Acute laryngitis, tracheobronchitis • Acute broncheolitis • Pneumonia • Bronchial asthma • Foreign body • Measels, pertusis • Chemical irritation

49. Acute cough: URT • Common cold (coryza) • Acute tonsillo-pharyngitis • Acute sinusitis • Acute laryngitis • Chemical irritation • Foreign body

50. Common Cold • What? Acute viral inflammation of mucous membrane of the nose and pharynx • Cause? Rhinoviruses • C/P? - Low grade fever -watery nasal discharge -sneezing -cough - signs of nasal congestion - unable to breast feed in infants