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RESPIRATORY SYSTEM I. Prof. Dr. Shahenaz Mahmoud Hussein. ACUTE BACTERIAL PHARYNGOTONSILITIS. Etiology: Group A streptococcal infection. Mycoplasma pneumonia. Chlamydia pneumoniae. Groups C and D streptococci. Complications: 1- Acute rheumatic fever. 2- Acute glomerulonephritis.

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respiratory system i


Prof. Dr. Shahenaz Mahmoud Hussein

acute bacterial pharyngotonsilitis


  • Group A streptococcal infection.
  • Mycoplasma pneumonia.
  • Chlamydia pneumoniae.
  • Groups C and D streptococci.


1- Acute rheumatic fever.

2- Acute glomerulonephritis.

3- Suppurative complications such as cervical adenitis, peritonsillar abscess, otitis- media, cellulitis, and septicemia.

Investigations: - Rapid antigen test : If positive indicates S Pyogenes infection, but a negative result require confirmation by culture.



  • For Group A streptococcal infection, give 10 days course of oral penicillin V potassium 250 mg bid, Cephalosporin, or IM Penicillin G benzathine penicillin 600,000 u for children < 27kg and 1,200,000 u for those >27kg.
  • Amoxacillin (50mg/kg for 10 days), Azithromycin (12mg/kg/d for 5 days), and Cefadroxil (30mg/kg/d for 10 days) these drugs given once daily.
  • In penicillin allergy give Erythromycin estolate 20mg/kg/d bid.
  • Trimethoprim - sulfamethoxazol is not an effective treatment for s. pyogenes.

Eradicate carrier state if the patient or another member of the family has frequent streptococcal infections, or when has a history of rheumatic fever or glomerulonephritis.

If the patient has had 3 or more documented infections within 6 months, daily penicillin prophylaxis may be needed during winter season.

Tonsillectomy indicated only when the patient had upper respiratory obstruction , or frequent episodes ,which defined as 7 episodes in 3 years, 5 episodes for 2 years or 3 episode for one year.

otitis media


1-Acute otitis media.

2-Otitis media with effusion.

3-Chronic suppurative otitis media.

1-Acute otitis media

Defined as inflammation of the middle ear resulting in an effusion and associated with rapid onset of symptoms such as otalgia, fever, irritability, anorexia, or vomiting.

Otoscopic finding: Bulging TM. yellow, white, or bright red color ; opicification of the eardrum.

Exudate or bullae on the eardrum.


2- Otitis media with effusion

Defined as an asymptomatic middle ear effusion that often follows acute OM, but may have no antecedent history.

Otoscopic findings: - Visualization of air-fluid levels or bubbles, and a clear or amber middle ear fluid.

-It is usually associated with mild to moderate conductive hearing impairment.

3- Chronic suppurative otitis media

-Defined as persistent otorrhea lasting longer than 6 weeks.

-It occurs more often in children with tympanostomy tubes or TM perforations.


Factors that lead to acute OM:

1- Nasopharyngeal colonization with S. pneumonia, Haemophilus influenza, or Moraxella catarrhalis.

2- Viral upper respiratory infections.

3- Smoke exposure.

4- Eustachian tube dysfunction.

5- Immunodeficiency states.

6- Breast feeding provide protective IgA antibodies.

7- Genetic susceptability.

Causative organisms:

Acute OM: 1- S. pneumonia 2- H.influenza

3- M.catarrhalis 4- S.pyogenes.

Chronic S.OM: 1- pseudomonas aeruginosa. 2- S.aureus

3-Resistent S.peumonia.



1- Pneumatic otoscope to assess mobility of TM.

2- Cerumen removal.

3- Tympanometry for children over 6 months.

4- Acoustic reflectometry to distinguish negative middle ear pressure from effusion.


1- Antibiotic therapy:

- First line: Amoxacillin 90mg/kg/d for 5 days, but in children <2 years give 10 days. Others: Cefuroxime, Zithromycin, or single dose IM Ceftriaxone.

-Second line: If no respone after 72 hours or recurrence within 4 weeks. Amoxacillin clavulanate.

-Third line: Tympanocentesis or Myringotomy and Ceftriaxone 3 doses IM in 3 days.

2- Pain management: Auralgan ear drops.

Prevention: Pneumococcal and haemophilus infleunza vaccines.


Croup syndromes

Group of acute infectious conditions characterized by a distinctively brassy cough which may be accompanied by inspiratory stridor, hoarseness and signs of respiratory distress due to varying degrees of laryngeal obstruction.

They include the following clinical varieties:

  • Acute laryngotracheobronchitis, ALTB viral group)
  • Acute diphtheritic laryngitis (diphtheritic croup)
  • Acute epiglottitis (bacterial croup)
  • Acute spasmodic laryngitis (spasmodic croup)
  • Bacterial tracheitis (membranous croup)

Acute Laryngotracheobronchitis

- Caused by para-influenza viruses types 1and 2

- Affects children between 6mo and 3yr of age.

- Seasonal peak: late fall and early winter.

Clinical Manifestations: The most common type

-The typical episode begins in a child having symptoms of an URTI and lasts less than 5 days.

- A brassy cough, hoarseness, inspiratory stridor and respiratory distress may develop slowly or acutely.

- As obstruction increases, the child becomes extremely restless with increasing RR and HR.

- Cyanosis is late sign and denotes complete airway obstruction.

- Symptoms are characteristically worse at night.


Acute Epiglottitis

- The most serious form of croup syndromes.

- Affects children between 2 and 7 yr of age.

- Caused by H. influenzae type b. - Characterized by a fulminating course of rapidly progressive airway obstruction.

Clinical Picture:- Abrupt onset of high fever, aphonia, drooling and moderate to severe respiratory distress with stridor.

- The child may prefer a sitting position, leaning forward with the mouth open and the tongue protruded.

- The inflamed airway may suddenly become totally obstructed leading to death.

- The temperature may be slightly elevated or as high as 39-40oC.

- Signs of upper airway obstruction are evident "labored breathing, marked suprasternal, intercostal and subcostal retractions".

- There are bilaterally diminished breath sounds, wheezing and scattered rales.



- Direct laryngoscopy demonstrates the inflamed and swollen supraglottic structures and cherry-red swollen epiglottis.

- Lateral neck airway radiograph reveals the "thumb sign" of a swollen epiglottis and normal subglottis.

- CBC shows leukocytosis.

  • Blood culture is positive for H. influenzae type b in more than 80% of cases.


- Latex particle agglutination for rapid diagnosis of H. influenzae b.

- Nasotracheal intubation or tracheotomy.

- Parenteral antibiotic therapy: Ceftriaxone, cefotaxime, or ampicillin-sulbactam should be given at once.

- Racemic epinephrine and corticosteroids are of limited value.

Prevention:Hib (H. influenzae type b) conjugate vaccine


Acute Spasmodic Laryngitis


may be allergic because of the recurrent nature.

Clinical Manifestations:

- There are brief repeated attacks of croup that are clinically similar to ALTB but less severe. The child will be a febrile and lack the viral prodrome.

- It occurs most often in children 1-3 yr of age.


It responds to simple therapies such as exposure to cool or moist air.

Bacterial Tracheitis

It is an acute bacterial infection of the trachea which is capable of causing life-threatening airway obstruction.


- S. aureus and H. influenzae are the most common organisms.

  • It follows a viral URTI i.e. bacterial complication of a viral disease.

Clinical features: Painful harsh cough, inspiratory stridor and sputum production.

Treatment:Antibiotics according according to culture of sputum.

Treatment of croup syndrome:

1- Humidification:-

-In mild cases, marked improvement occurs when the child is taken into the cool night air or into the bathroom with a warm shower.

- Cool mist administered by tent or face mask may help to prevent drying of secretions around the larynx.


Treatment continue:

2. Epinephrine: - Racemic epinephrine inhalation therapy is a cornerstone in symptomatic relief during exacerbations of ALTB. It temporarily reduces edema leading to marked clinical improvement.

- Racemic epinephrine solution (2.25%): 0.25 ml for infants less than 6mo. of age; 0.5 ml more than 6mo. of age is added to 2.5 ml of sterile water or normal saline and nebulized over 15 min.

3. Steroids: - They are beneficial for seriously ill patients.

*Decrease inflammatory edema and prevent destruction of ciliated epithelium.

*Reduce the need for more racemic epinephrine or an artificial airway.

- Dexamethasone sodium phosphate as a single dose of 0.5 mg/kg. It has a long er half-life of 36-72hr with onset after 3hr.

4. Intubation:When therapy fails to alleviate the symptoms, an artificial airway is indicated, either nasotracheal intubation or tracheostomy.


Causes of stridor:

I- Obstruction

1) In the lumen: Foreign body or mucus.

2) In the wall: by edema which may be.

- Allergic: angioedema.

- Inflammatory: laryngitis, tracheitis.

3) Pressure from outside by:

- Retrosternal goiter.

- Anomalous aortic arch or vascular ring.

- Mediastinal tumors.

II- Neuromuscular:

Hyperexcitability of nerves as in tetany causing spasm of laryngeal muscles (laryngismus stridulus).

III- Congenital laryngeal stridor:

Laryngomalacia and tracheomalacia