Respiratory System

1. Respiratory System Dr. ShreedharPaudel 17/03/2009

2. A Clinical Case • A mother brings her 9 months old baby to ER with the complain of fever and fast breathing for 3 days. • On examination- temperature is 102 degree F, RR is 65/min, sub-costal indrawing is present, dull on percussion over right chest but no abnormal sound heard on auscultation. • What is your provisional diagnosis? • What should be your next step?

3. Pneumonia • Previously known as pneumonitis • Inflammation of parenchyma of lungs • Pathologically– consolidation of alveoli & infiltration of interstitial tissue with inflammatory cell

4. Classifications • Simple Classification --Community Acquired --Hospital Acquired • Etiological Classification --Chemical Pneumonia eg- ingestion of kerosene --Aspiration Pneumonia eg-vomiting, aspiration

5. Etiological Classification contd….. • Viral Pneumonia --RSV, Adeno virus, Influenza, Parainfluenza • Bacterial Pneumonia --Pneumococcus, Staphylococcus, H. Influenzae, Streptococcus, Klebsiella • Atypical Pneumonia --Chlamydia, Mycoplasma, Pneumocystiscarinii

6. Etiological Classification contd….. • Fungal Pneumonia --Histoplasmosis --Coccidiomycosis • Metazooal --Ascaris as in Loeffler’s Syndrome • Hypersensitivity

7. Etiology is different depending on the age • <2 months --Group B Streptococci • 2 mo-5 yrs --H. influenzae --Streptococcus pneumoniae • >5 years --Mycoplasma pneumoniae

8. Note! No one can differentiate the type of pneumonia just by looking at the patient with 100% sensitivity & specificity

9. WHO Classification of Pneumonia • No pneumonia • Pneumonia • Severe pneumonia • Very severe pneumonia • Important to manage pneumonia cases in communities of developing and underdeveloped countries!

10. Clinical features • Symptoms --Cough→ entry point ( all patient will have) --Fast breathing , breathlessness --Excessive crying --Acute abdominal emergency →rarely in case of basal pneumonia due to referred pain from pleura --High fever --Diarrhoea

11. Symptoms contd… --Headache --Pain in shoulder → drooping of shoulder --Meningism ( If upper lobe involved ) ↓ rigor, convulsion lethargy headache neck stiffness --Turning blue

12. Clinical signs • Vitals: --Temperature: ↑ --Respiratory Rate: ↑ --Blood Pressure: Normal or↓ if in septic shock after pneumonia– detected by capillary refilling time (CRT) • Rigor, Cyanosis • Chest signs

13. Chest signs contd….. • Inspection—Indrawings; diminished movement or expansion on the side affected; Rash (if any infection) • Palpation--↑vocal resonance • Percussion—Dull on the affected side • Auscultation—Basal crepitations to wheezing (during expiration)– usually B/L(if U/L– Asthma)

14. Cut off of fast breathing for the diagnosis of pneumonia AGE RR/Min < 2 months 60 or more 2mo-11mo 50 or more 12mo-5yrs 40 or more Eg, in a 3 year old – cough and fever with RR-50/min ↓ pneumonia ( no need of steths)

15. Investigations • CXR—may not have any changes in early disease. --findings depend on the causative organism

16. X-Ray Feature of Pneumonia

17. X-Ray Feature of Pneumonia contd…. • Lobar Pneumonia

18. This chest x-ray shows cloudiness throughout the lungs, caused by acute pneumonia following chickenpox. Pneumonia, as a complication of chickenpox, rarely occurs in children, but occurs in about one-fifth of adults.

19. Investigations contd….. • Blood count --↑ WBC (leucocytosis) --Toxic granules & shift to the left ( immature cells→ means infection is very severe so cells are produced very fast) • Blood culture --positive in 5-15% of cases • Sputum gram staining & culture

20. Investigations contd….. • C-Reactive Protein --↑Acute phase reactant • ABG (Arterial Blood Gas) Analysis --done in severe cases --Acidosis

21. Management of Pneumonia

22. Management of Pneumonia…….

23. Reassessing the child with Pneumonia • If getting worse—not able to drink --increased chest indrawings --signs of very severe disease ↓ examine for complications and switch to Cloxacillin and Gentamycin if Staph. pneumoniae is suspected. • If not improving—but no signs of severe disease ↓ switch antibiotics from 1st line →2nd line

24. Oral Antibiotics for Pneumonia • 1st line : Cotrimoxazole—х2 х5 days • 2nd line : Amoxycillin– х3 х5 days NOTE! • Fever is controlled with paracetamol—child with ↑RR which is even increased by fever may go to respiratory failure • Never cold sponge a child with pneumonia-- ↑crying & oxygen requirement-- ↑RR—respiratory failure

25. Contd….. • Never prescribe steroids as it ↓immunocompentency • Cough syrup– DEATH prescription • Calorie & fluid—child is dehydrated --mother—sips of fluid --if iv fluid—give 1/3rd of total requirement (children with pneumonia may have inappropriate ADH –pulmonary edema, cardiac failure & respiratory failure)

26. Complications of Pneumonia • Pulmonary --collapse --lung abscess & rupture --pneumatocele --delayed resolution • Pleural --fibrinous pleurisy & adhesions --pleural effusion ( less likely) --empyema --pneumothorax (Staph pneumoniae)

27. Contd… • Airway --Bronchiectasis—cough (foul smelling) --ottitis media --sinusitis --bronchopleural fistulas • Cardiac --pericarditis/myocarditis (mortality very high) --pericardial effusion --endocarditis --shock

28. Contd…. • Cardiac contd… --arrythmias --pulmonary edema --CCF • Extrathoracic --septecimia --herpes labialis --metastatic infection (meningitis,arthritis, osteitis, peritonitis)

29. Contd… • Toxic & metabolic --Acidosis --acute hemolytic anaemia --febrile convulsions --SIADH

30. 1 and ½ yr old M child presented in the middle of the night with noisy breathing --parents were afraid & it increased when child was excited O/E—running nose --100 F temp --no chest indrawing --non toxic --RR not increased

31. Acute laryngotracheobronchitis(CROUP) • Commonest form of acute upper airway obstruction --usually viral, bacterial infection may occur --usually subside within 48 hrs

32. Causative organisms • Parainfluenza virus types 1, 2 & 3 are the most important infectious agents • influenza virus type A & B, respiratory syncytial virus, adenovirus, rhinovirus and enteroviruses are also common • herpes viruses and bacteria like Haemophilus influenza type B and Staphylococcus aureus –rare cases

33. Clinical Features • Usually starts with rhinorrhoea, sore throat, and mild fever for few days • Then develops the characteristic barking cough, hoarseness,respiratory distress, and inspiratory stridor, with or without the persistence of the low-grade fever • Symptoms tend to be worse at night but child is usually not acutely ill

34. Clinical Features contd…. • Drooling is not common in viral croup • Agitation & crying aggravate the symptoms Note! --incidence of viral croup peaks in the winter months --91% of cases occur in less than 5 years of age --most cases occur before 2 years --slight male preponderance

35. Investigations • Complete blood picture --mild leucocytosis and lymphocytosis(very non-specific) ( does not help the diagnosis and will not alter the management--painful procedure and should be avoided) • Arterial blood gas --only in very severe or intubated cases • Lateral neck radiograph --not necessary in obvious case (may be considered in stable patients with suspected foreign body or anatomical abnormalities)"steeple sign"

36. Steeple sign

37. Steeple sign

38. Management • Mild cases--managed in out patient clinic (provided signs of deterioration can be watched out for)-- increasing stridor, increasing respiratory distress and increasing fatigue. • A calm and warm environment, minimal disturbance together with parenteral comfort is all that needed in most cases of the mild croup.

39. Management contd… • Corticosteroids --effective in reducing acute symptoms in moderate to severe cases (Oral administration is as effective as parenteral) • Nebulizer Steroid Therapy --as Efficient as Systemic Steroid in Reducing Acute Symptoms

40. Other Supportive Management • 1) Oxygen --Routine oxygen supplement is not necessary --given if the child has progressive tachypnoea, tachycardia, cyanosis and laboured breathing • 2) Fluid--Maintain hydration by encouraging oral fluid intake -- iv fluid supplement --very distress child. --Over-hydration should be avoided.

41. Other Supportive Management contd… • Intubation --rarely needed but act if necessary • Routine chest physiotherapy is not recommended-- may also aggravate the already distressed child. • Humidified Air • Antibiotic is not recommended unless bacterial infection is clinically likely to be present.

42. Respiratory disorders contd… Dr ShreedharPaudel 18/03/2009

43. Two years old child presented in ER with increased respiartory rate and Increased temperature, looks toxic and there is drooling of saliva from the mouth What is the diagnosis?

44. Acute Epiglottitis “A very rapidly progressive infection causing inflammation of the epiglottis (the flap that covers the trachea) and tissues around the epiglottis that may lead to abrupt blockage of the upper airway and death”

45. Causative organism • Usually Bacterial in origin --Hemophilus influenzae (commonest) --Streptococcus pneumoniae --Staphylococcus aureus --Streptococci • Incidence has decreased secondary to Haemophilus influenzae immunization

46. Symptoms of Epiglotitis Abrupt and rapid onset of • Sore throat (may refuse to eat) • High fever • Breathing changes • Breathing difficulty • Open mouthed breathing • Breathing with tongue out • Stridor (Noisy breathing)

47. Symptoms of Epiglotitis contd.. • Cough—sometimes • Excess saliva secretion • Drooling( 80% of patients) • Voice changes “clinical triad of drooling, dysphagia, and distress is the classic presentation”

48. Signs of Epiglotitis • Patient appears acutely ill, anxious • Assumes characterstic TRIPOD sign if old enough to do so (child to lean forward and hyperextend the neck to enhance air exchange) • Rapid pulse • Cyanosis • older child, pain may be noted on movement of the hyoid bone

49. “Acute epiglotitis is a paediatric emergency” • Do not --panic --alarm the parents or child --examine the child in any way - especially do not try to visualize the epiglottitis using a tongue depressor (provoke spasm and cause obstruction)

50. Do’s • Call a senior anaesthetist, paediatrician and ENT surgeon in case required • Minimise distress to the child - don't separate from parents