Wheezing in children. Asthma.

1. Wheezing in children. Asthma.

2. Normal breathing rates for children Newborn 40-60 breaths per minute 1-6 months 30-40 breaths per minute 6-12 months 24-30 breaths per minute 1 to 5 years 20-30 breaths per minute 6 to 12 years 12-20 breaths per minute

3. When a child has tachypnoe? < 2 months > 60 breaths per minute 2-12 months > 50 breaths per minute 2 to 5 years > 40 breaths per minute >5 years > 30 breaths per minute

4. Stridor and wheezing – symptoms of airway obstruction Stridor is a harsh sound caused by a partially obstructedextrathoracic airway, more commonly heard on inspiration Wheezing is produced by partial obstruction of the lower airways,more commonly heard during exhalation.

5. Causes of Wheezing in Childhood Acute Chronic or Recurrent

6. Causes of acute wheezing Reactive airway disease (asthma, hipersensitivity reactions) Bronchial edema (infection, inhalation of irritant gases or particulates, increased pulmonary venous pressure) Bronchial hypersecretion (infection, inhalation of irritant gases or particulates, cholinergic drugs) Aspiration (foreign body, aspiration of gastric contents)

7. Causes of chronic or recurrent wheezing Reactive airway disease (asthma, hipersensitivity reactions) Dynamic airway collapse (Bronchomalacia/tracheomalacia, vocal cord adduction) Airway compression by mass or blood vessel (vascular ring, anomalous innominate artery, pulmonary artery dilatation, bronchial or pulmonary cysts, lymph nodes (tuberculosis, lymphoma)

8. Causes of chronic or recurrent wheezing 4. Aspiration (foreign body, gastroesophagealreflux, tracheoesophagealfistula) 5. Bronchialhypersecretionorfailure to clear secretions (bronchitis, bronchiectasis, cysticfibrosis, primaryciliarydyskinesia) 6. Intrinsicairwaylesions (endobronchialtumorse.g.carcinoid, endobronchialtuberculosis, bronchialortrachealstenosis, bronchiolitisobliterans 7. Congestiveheartfailure

9. TRACHEOMALACIA • Tracheomalacia is a floppy trachea due to lack of structural integrity of the tracheal wall. • The tracheal cartilaginous rings normally extend, maintaining rigidity of the trachea during changes in intrathoracic pressure. • With tracheomalacia, the cartilaginous rings may not extend as far around the circumference, be completely absent, or may be present but damaged. • These abnormalities can result in excessive collapse of the trachea, most pronounced during expiration. • Tracheomalacia may be congenital (e.g. tracheoesophageal fistula) or acquired (long-term mechanical ventilation).

10. TRACHEOMALACIA • Tracheomalacia must be differentiated from extrinsic tracheal compression by masses or vascular structures. • Viral infections may exacerbate tracheomalacia, leading to coarse expiratory wheezing and barky cough. • The expiratory noises of tracheomalacia are often mistakenly ascribed to asthma or bronchiolitis, and the barky cough is often misdiagnosed as croup.

11. TRACHEOMALACIA • With tracheomalacia, the tracheal collapse may only be apparent during forced exhalation or with cough. • The airway collapse may cause recurrent coarse expiratory wheeze and a prolonged expiratory phase. • Secretions may be retained behind the segment of malacia, predisposing to infection.

12. TRACHEOMALACIA • Infants with severe tracheomalacia may completely collapse their tracheas during agitation, resulting in cyanotic episodes • In older children, the hallmark sign is a brassy, barky cough due to the vibration of the tracheal walls. • This cough can be loud and persistent and is often misdiagnosed as croup.

13. TRACHEOMALACIA • Infants with mild to moderate tracheomalacia usually require no intervention. • Tracheomalacia improves with airway growth as the lumen increases in diameter and the trachealwall becomes more firm • The treatment of older symptomatic children is geared toward treating any precipitating cause for cough and providing supportive care. • Antibiotics may be necessary to treat an infection.

14. TRACHEOMALACIA • Children, especially infants, with severe tracheomalacia may require tracheostomy tubes to administer continuous positive airway pressure(CPAP), which serves to stent open the airway. • Surgically placed airway stents are problematic in children because the stents cannot grow and thus serve as a source of fixed stenosis and obstruction.

15. ExtrinsicTrachealCompression • Compression of the trachea by vascular structures or masses can cause significant respiratory problem. • Tracheal compression by aberrant great vessels (aorta, innominate artery) may cause wheezing, stridor, cough, and dyspnea, dysphagia • This usually results in mild respiratory symptoms, and surgical correction is rarely necessary.

16. ExtrinsicTrachealCompression • The diagnosis of vascular anomalies can often be made by a barium swallow, which identifies the esophageal compression. • Bronchoscopy will identify a pulsatile compression of the airway, but the diagnostic procedure of choice is a computed tomography (CT) angiogram of the chest and great vessels. • Other causes of extrinsic tracheal compression include enlarged mediastinal lymph nodes (tuberculosis), mediastinal masses (teratoma, lymphoma, thymoma, germ cell tumors)

17. Foreign Body Aspiration • Aspiration of foreign bodies into the trachea and bronchi is relatively common. • The majority of children who aspirate foreign bodies are under 4 years of age. • Most deaths secondary to foreign body aspiration occur in this age group.

18. Foreign Body Aspiration • Because the right mainstem bronchus takes off at a less acute angle than the left mainstem bronchus, foreign bodies tend to lodge in right-sided airways. • Some foreign bodies, especially nuts, can also lodge more proximally in the larynx or subglottic space, totally occluding the airway. • Many foreign bodies are not radiopaque, which makes them difficult to detect radiographically.

19. Foreign Body Aspiration • The most common foreign bodies aspirated by young children are food (especially nuts) and small toys. • Coins more often lodge in the esophagus than in the airways. • Older children have been known to aspirate rubber balloons, which can be life-threatening.

20. PrimaryCiliaryDyskinesia • Primary ciliary dyskinesia (PCD, immotile cilia syndrome) is an inherited disorder in which ultrastructural abnormalities in the cilia result in absent or disordered movement of the cilia. • This disorder affects approximately 1 in 19,000 persons.

21. PrimaryCiliaryDyskinesia • The classicpresentationisrecurrentotitis media, chronicsinusitis, cough, wheezing. • Kartagenersyndrome, the triad of situsinversus, pansinusitis, and bronchiectasis, accounts for approximately 50% of cases. Malesareinfertile as a result of immotile sperm.

22. PrimaryCiliaryDyskinesia • Because the cilia fail to beat normally, secretions accumulate in the airways, and endobronchial infection results. • Chronic infection, if untreated, leads to bronchiectasis by early adulthood. • Primary ciliary dyskinesia should be suspected in patients with early-onset chronic bronchitis or bronchiectasis associated with recurrent/persistent sinusitis and/or frequent otitis media.

23. PrimaryCiliaryDyskinesia • PCD is confirmed by electron microscopy of respiratorycilia, obtained from scrapings/biopsy of nasal or airwayepithelium.

24. PrimaryCiliaryDyskinesia • Treatment is geared toward treating infections and improving clearance of respiratory secretions. • High resolution chest CT scans are useful to confirm and monitor bronchiectasis. • Cultures help identify organisms involved and guide antibiotic therapy

25. PrimaryCiliaryDyskinesia • Sinus surgical procedures are often done to manage chronic sinusitis, but their benefit is questionable. • Chest physiotherapy and prompt treatment of bacterial infections are helpful, but the course of the disease tends to be slowly progressive. • Preventive antibiotics (macrolides) may reduce the number of exacerbations

26. ASTHMA

27. Asthma • Asthma is a chronic lung disease that inflames and narrows the airways. • Asthma causes recurring periods of wheezing, chest tightness, shortness of breath and coughing. • The coughing often occurs at night or early in the morning

28. Asthma • Asthma affects people of all ages, but it most often starts during childhood. • In the United States, more than 25 milion people are known to have asthma. • About 7 milion of these people are children.

29. Asthma - interview • The interview should include the frequency, severity, and factors that worsen the child’s symptoms as well as a family history of asthma and allergy. • Exacerbating factors include viral infections, exposure to allergens and irritants (e.g., smoke, strongodors), exercise, emotions, and change in weather/humidity. • Nighttime symptoms are common.

30. Asthma – physical examination • During acute episodes, tachypnea, tachycardia, cough, wheezing, and a prolonged expiratory phase may be present • Physical findings may be subtle. Classic wheezing may not be prominent if there is poor air movement from airwayobstruction • As the attack progresses, cyanosis, diminishedair movement, retractions, agitation, inability to speak, tripodsitting position, diaphoresis, and pulsusparadoxus (decreasein blood pressure of >15 mm Hg with inspiration) may beobserved. • Physical examination may show evidence of otheratopic diseases such as eczema or allergic rhinitis

31. Asthma – diagnosis in children > 5 years • Interview • Physical examination • Spirometry • PEF (peak expiratory flow)

32. Asthma – diagnosis in children < 5 years • ASTMA PREDICTIVE INDEX • Good clinical response to inhaled glucocorticosteroids (ICS) • Exclusion of other causes of wheezing

33. ASTMA PREDICTIVE INDEX (API) High-riskchildren (under agethree) whohavehadfourormorewheezingepisodesinthe past yearthatlastedmorethan one day, and affectedsleep, are much morelikely to havepersistentasthmaaftertheage of five, iftheyhaveeither of thefollowing: One major criteria: • Parentwithasthma • Physiciandiagnosis of atopicdermatitis (eczema) • Evidence of sensitization to allergensinthe air OR Two minor criteria: • Evidence of foodallergies • 4 percentormorebloodeosinophilia • Wheezingapartfromcolds

34. ASTMA PREDICTIVE INDEX (API) • The API was developed after following almost a thousand children through 13 years of age. • Seventy-six (76%) of children diagnosed with asthma after six years of age had a positive asthma predictive index before three years of age • Ninety-seven (97%) of children who did not have asthma

39. HAVE A NICE DAY 