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Respiratory System. Dr. Shreedhar Paudel 17/03/2009. A Clinical Case. A mother brings her 9 months old baby to ER with the complain of fever and fast breathing for 3 days.

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respiratory system

Respiratory System

Dr. ShreedharPaudel

17/03/2009

a clinical case
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?
pneumonia
Pneumonia
  • Previously known as pneumonitis
  • Inflammation of parenchyma of lungs
  • Pathologically– consolidation of alveoli & infiltration of interstitial tissue with inflammatory cell
classifications
Classifications
  • Simple Classification

--Community Acquired

--Hospital Acquired

  • Etiological Classification

--Chemical Pneumonia eg- ingestion of kerosene

--Aspiration Pneumonia eg-vomiting, aspiration

etiological classification contd
Etiological Classification contd…..
  • Viral Pneumonia

--RSV, Adeno virus, Influenza, Parainfluenza

  • Bacterial Pneumonia

--Pneumococcus, Staphylococcus, H. Influenzae, Streptococcus, Klebsiella

  • Atypical Pneumonia

--Chlamydia, Mycoplasma, Pneumocystiscarinii

etiological classification contd6
Etiological Classification contd…..
  • Fungal Pneumonia

--Histoplasmosis

--Coccidiomycosis

  • Metazooal

--Ascaris as in Loeffler’s Syndrome

  • Hypersensitivity
etiology is different depending on the age
Etiology is different depending on the age
  • <2 months

--Group B Streptococci

  • 2 mo-5 yrs

--H. influenzae

--Streptococcus pneumoniae

  • >5 years

--Mycoplasma pneumoniae

slide8

Note!

No one can differentiate the type of

pneumonia just by looking at the patient with 100%

sensitivity & specificity

who classification of pneumonia
WHO Classification of Pneumonia
  • No pneumonia
  • Pneumonia
  • Severe pneumonia
  • Very severe pneumonia
    • Important to manage pneumonia cases in communities of developing and underdeveloped countries!
clinical features
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

symptoms contd
Symptoms contd…

--Headache

--Pain in shoulder → drooping of shoulder

--Meningism ( If upper lobe involved )

rigor, convulsion

lethargy

headache

neck stiffness

--Turning blue

clinical signs
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
chest signs contd
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)
cut off of fast breathing for the diagnosis of pneumonia
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)

investigations
Investigations
  • CXR—may not have any changes in early disease.

--findings depend on the causative organism

slide18

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.

investigations contd
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
investigations contd20
Investigations contd…..
  • C-Reactive Protein

--↑Acute phase reactant

  • ABG (Arterial Blood Gas) Analysis

--done in severe cases

--Acidosis

reassessing the child with pneumonia
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

oral antibiotics for pneumonia
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
contd
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)

complications of pneumonia
Complications of Pneumonia
  • Pulmonary

--collapse

--lung abscess & rupture

--pneumatocele

--delayed resolution

  • Pleural

--fibrinous pleurisy & adhesions

--pleural effusion ( less likely)

--empyema

--pneumothorax (Staph pneumoniae)

contd27
Contd…
  • Airway

--Bronchiectasis—cough (foul smelling)

--ottitis media

--sinusitis

--bronchopleural fistulas

  • Cardiac

--pericarditis/myocarditis (mortality very high)

--pericardial effusion

--endocarditis

--shock

contd28
Contd….
  • Cardiac contd…

--arrythmias

--pulmonary edema

--CCF

  • Extrathoracic

--septecimia

--herpes labialis

--metastatic infection (meningitis,arthritis, osteitis, peritonitis)

contd29
Contd…
  • Toxic & metabolic

--Acidosis

--acute hemolytic anaemia

--febrile convulsions

--SIADH

slide30

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

acute laryngotracheobronchitis croup
Acute laryngotracheobronchitis(CROUP)
  • Commonest form of acute upper airway obstruction

--usually viral, bacterial infection may occur

--usually subside within 48 hrs

causative organisms
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
clinical features33
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
clinical features contd
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

investigations35
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"
management
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.
management contd
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
other supportive management
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.

other supportive management contd
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.
respiratory disorders contd

Respiratory disorders contd…

Dr ShreedharPaudel

18/03/2009

slide43

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?

acute epiglottitis
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”

causative organism
Causative organism
  • Usually Bacterial in origin

--Hemophilus influenzae (commonest)

--Streptococcus pneumoniae

--Staphylococcus aureus

--Streptococci

  • Incidence has decreased secondary to Haemophilus influenzae immunization
symptoms of epiglotitis
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)
symptoms of epiglotitis contd
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”

signs of epiglotitis
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
acute epiglotitis is a paediatric emergency
“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)

slide50
Do’s
  • Call a senior anaesthetist, paediatrician and ENT surgeon in case required
  • Minimise distress to the child - don't separate from parents
investigations51
Investigations
  • Securing an airway is the overriding priority. All further evaluations should follow
  • CBC—leucocytosis
  • Blood cultures and culture of the epiglottis –only after airway secured
investigations contd52
Investigations contd….
  • Blood cultures are positive in less than 15% of cases caused by H influenzae.
  • Epiglottic cultures are positive in 50% of cases caused by H influenzae
  • Lateral cervical X-Ray—swelling of the epiglottis (THUMB sign)
  • Diagnostically radiology is rarely required, and delaying treatment in order to image the child is inappropriate
differential diagnosis
Differential diagnosis
  • Bacterial tracheitis
  • Foreign body trachea
  • Anaphylaxis
  • Retropharyngeal abscess
management56
Management
  • Confirm immunization status
  • Admit to ward if

--stridor at rest

--inability to take fluid

--respiratory distress

  • If child is in respiratory distress

--Oxygen supplementation

--Tracheostomy if needed

--Nebulised vapour may be useful

management contd57
Management contd….
  • Open iv line (as child can’t take orally)-maintain adequate hydration
  • Antibiotics—Ceftriaxone (drug of choice for H. influenzae)—chloramphenicol is also equally effective
slide58

6/12 yrs, M child presented in the month of January with

--noisy breathing

--wheeze( with chest indrawing)

--100 F temp

--past h/o running nose for few days

-- very irritable

--↑ RR

On examination

--B/L Ronchi & crepetations

bronchiolitis
Bronchiolitis
  • Inflammation of the small passages in the lungs (bronchioles), usually caused by a viral infection
  • As these airways become inflamed, they swell and fill with mucus, making breathing difficult.
  • occurs during the fall and winter months.
bronchiolitis61
Bronchiolitis…..
  • most often affects infants and young children because their small airways can become blocked more easily than those of older kids or adults
  • typically occurs during the first 2 years of life, with peak occurrence at about 3 to 6 months of age
  • is more common in males, children who have not been breastfed, and those who live in crowded conditions, day-care centers.
causative organisms62
Causative organisms
  • RSV (Respiratory Synctial Virus)—commonest
  • Adenovirus
  • Influenza virus
  • Parainfluenza virus

“Transmission-- Droplet”

risk factors
Risk factors
  • Being exposed to cigarette smoke
  • Being younger than 6 months old
  • Living in crowded conditions
  • Never being breastfed
  • Prematurity (born before 37 weeks gestation)
symptoms
Symptoms
  • Cough, wheezing, shortness of breath, or difficulty breathing –opening symptoms
  • Other symptoms
    • Fever
    • Cyanosis
    • Grunting
    • Vomiting, especially post-tussive
    • Irritability
    • Poor feeding or anorexia
signs
Signs
  • Tachypnea, often at rates over 50-60 breaths per minute (most common physical sign)
  • Tachycardia
  • Fever, usually in the range of 38.5-39°C
  • Mild conjunctivitis or pharyngitis
  • Diffuse expiratory wheezing
  • Nasal flaring
signs contd
Signs contd….
  • Intercostal retractions
  • Cyanosis
  • Inspiratory crackles
  • Otitis media
  • Apnea, especially in infants younger than 6 weeks
  • Palpable liver and spleen from hyperinflation of the lungs and consequent depression of the diaphragm
differential diagnosis67
Differential diagnosis
  • Asthma
  • Bronchitis
  • Pneumonia
  • Foreign body inspiration
  • Congestive hear failure
investigations68
Investigations

“Rarely required for the diagnosis”

  • Chest X-Ray--↑ed lung markings

--flattening of diaphragm

  • Pulseoximeter to measure oxygen levels
  • Blood count—usually not helpful
treatment
Treatment

“Sometimes no treatment required”

  • Oxygen— “only drug” (bronchodilators useless)
  • Adequate hydration and calorie—IV drip but with caution if SIADH (give 1/3rd of total requirement)
  • Wait and watch

“After around 3 days the illness subsides”

treatment contd
Treatment contd….
  • Sometimes Rivabirin (nebulized)—in literatures—50% success rate
  • Severe cases—Digoxin (in view of possibility of CHF)
  • Respiratory acidosis if present—correction
remember
Remember
  • No anti cough mixture & antibiotics—worsens—death
  • Never use nebulized vapour—as vapourized particles increase the obstruction in the bronchioles that have narrowed.