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An approach to a child with respiratory symptoms. Dr. Pushpa Raj Sharma Professor of Child Health Institute of Medicine. Cough Runny nose Tachypnoea Snoring Stridor Wheeze. Chest pain Chest indrawing Haemoptysis Bluish discoloration. Common respiratory symptoms.

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an approach to a child with respiratory symptoms

An approach to a child with respiratory symptoms

Dr. Pushpa Raj Sharma

Professor of Child Health

Institute of Medicine

common respiratory symptoms
Cough

Runny nose

Tachypnoea

Snoring

Stridor

Wheeze

Chest pain

Chest indrawing

Haemoptysis

Bluish discoloration

Common respiratory symptoms
the most important sign tachypnea
The most important sign: Tachypnea
  • Cut off rate per minute
    • Less than 1 week up to 2 months: 60 or more
    • 2 months up to 12 months: 50 or more
    • 12 months up to 5 years: 40 or more.
  • Pathophysiology:
    • Hypoxaemia
    • Pulmonary oedema
    • Parenchymal inflammation
    • Restricitve/obstructive diseases
the most severe sign apnoea
The most severe sign: Apnoea
  • Acute life threatening event:
    • Apnoea > 20 second or associated with pallor, cyanosis, convulsion or limpness.
  • Aetiology:
    • Prematurity
    • Sepsis
    • Meningitis/encephalitis
    • Drugs
    • Abnormal muscle tone
cough
Cough
  • Commonest respiratory symptom.
  • Physiological to remove excess secretions or foreign body.
  • Cough receptors in the posterior pharynx and large bronchi.
  • Vagus/ glossopharyngeal: afferent to cough centre –pons /medulla. Efferent to - larynx/ diaphragm/ chest wall/abdominal wall/pelvic
  • Acute: lasts less than 2 weeks.
  • Chronic: lasts more than 2 weeks.
cough relating to time posture
Cough relating to time/ posture
  • During or after feeding: aspiration
  • Night: asthma/ post nasal drip
  • Morning: bronchiectasis
  • With exercise: asthma
  • Absence during play: psychogenic
  • Seasonal: allergen
  • Cold: hyperreactivity
differential diagnosis of chronic cough
Infants:

Infections

Chlamydia

Pertussis

Bronchiolitis

Non infectious

Asthma

Domestic smoke pollution/passive smoke

Gasro-eso. Reflux

Foreign body

Congenital anamolies

Tracheo-eso. fistula

Children

Infectious

Pneumonia

Croup

Post nasal drip/sinusitis

Non infectious

Asthma

Foreign body

Tropical eosiniphilia

Environmental irritants

Psychogenic

Differential diagnosis of chronic cough
treatment of chronic cough
Treatment of chronic cough
  • Over the counter cold preparation:
    • no beneficial effect in children under 5 years.
  • Post nasal drip:
    • Propped up position at 30 degree.
    • Treat accordingly for Allergic/non allergic rhinitis; Sinusitis
  • Macrolides: if Mycoplasma / chlamydia suspected.
  • Nasal steroids/ decongestant
  • Bronchodilators/ steroids
  • Specific treatment
psychogenic cough
Psychogenic Cough
  • School aged children.
  • The child is often a high achiever; family stress
  • Fixed timing but disappears during sleep and when distracted.
  • Diagnosis by observation and exclusion of other causes.
  • Treatment: Counseling, Normal saline gargle
noisy breathing
Snoring

Grunting

Stridor

Wheeze

Ronchi

Noisy Breathing
snoring
Snoring
  • Inspiratory harsh sound irregularly
  • Associated with: large tonsils and adenoids; micrognathia, macroglossia, palatal palsy, pharyngeal hypotonia, obesity
  • Diagnostic test:
    • Sleep study, flexible bronchoscopy, lateral x-ray neck
  • Treatment needed if:
    • Sleeping difficulty; daytime somnolence, enuresis, growth failure, morning headache.
stridor
Stridor
  • Inspiratory harsh sound continuously.

Can occur during expiration (intrathoracic) or both phase of respiration.

  • Asses the severity
    • Drooling of saliva, respiratory distress, unable to swallow, cyanosis
  • Common causes:
    • Infective: epiglottitis, laryngotracheobronchitis, tracheitis, retropharyngeal abscess (rare)
    • Malignancy: tumor compression, papilloma
    • Allergic: angioneurotic oedema.
    • Congenital: laryngomalacia, laryngeal web, vascular ring,
    • Aspiration: foreign body.
    • Neuronal: paralysis of vocal cord.
  • Investigation
    • Blood count; Lateral neck X-ray; flexible bronchoscopy.
grunting
Grunting
  • Low pitched expiratory sound.
  • Protective phenomenon to prevent collapse of alveoli: PEEP
  • Causes:
    • Respiratory distress syndrome
    • Severe pneumonia, ARDS, severe sepsis
  • Investigations:
    • CXR; O2 saturation, blood gas
a child who wheezes all wheezes are not asthma
A child who wheezes: All wheezes are not Asthma
  • Cough could be the only symptom.
  • Triggering factor
  • Worse at night
  • History of repeated problem.
  • Symptomatic improvement with bronchodilator.
  • Gastro-esophageal reflux: Prokinetic.
causes of wheeze ronchi
Bilateral

Asthma

Bronchiolitis

Mycoplasma

Cystic fibrosis

Alpha 1 antitrypsin deficiency

Severe pneumonia

Unilateral

Pneumonia

Foreign body

Mediastinal mass

Tuberculosis

Bronchiectasis

Vascualr ring

Causes of Wheeze/Ronchi
chest pain rarely cardiac origin in children
Chest Pain: Rarely cardiac origin in children.
  • Infective
    • Pneumonia; pleural effusion, pneumothorax.
    • Born Holm disease
  • Asthma
  • Trauma
  • Costochondritis
  • Psychogenic
  • Pericardial lesions
the severe signs chest indrawing and cyanosis
Chest in drawing:

Increased airway resistance.

Contraction of diaphragm and pulling of ribs inside.

Negative pressure inside

Breathing in and lower chest wall goes in.

Supra sternal, inter costal recession.

Cyanosis:

Vasomotor instability in acrocyanosis.

Defective perfusion.

Defective ventilation.

Defective diffusion.

Methhaemoglobinemia

Hyperoxia test

The severe signs: Chest Indrawing andCyanosis
haemoptysis not common
Haemoptysis: not common
  • Blood from posterior naso-pharynx or hematemesis: the difference.
  • Aetiology:
    • Bronchiectasis.
    • Severe cough
    • Pneumonia
    • Paragonimiasis
    • Foreign body
    • Severe measles
    • Haemangioma/ AV malformation