Respiratory Disorders in Children

Celia Sy, M.D. FPPS,FPAPP Pediatric Pulmonologist

Anatomy

URT

LRT

Dilated esophagus

Stages of Lung Development

1. Embryonic Approx 4th wks of gestation Develop of the 2 main stem bronchus Seperation of forgut fr coelomic cavity

2. Pseudoglandular 6th weeks of gestation Separation of trachea from forgut Formation of diaphragm

Chest X-Ray

The Intensive Course in Pediatric PulmonologyCongenital Diaphragmatic Hernia

3. Cannalicular 16th and 26-28th weeks of gestation Presence of type I & II pneumatocytes Limited gas exchanges by 22 wks

4. Saccular 26th-28th wks of gestation Widen of terminal airways & saccule formation

5. Alveolar 29th wks – birth

Question 1

Tracheoesophageal fistula is formed at what stages of lung development? Pseudoglandular stage

Diaphragmatic hernia is formed at what stages of lung development? Pseudoglandular stage

Gas exchange is first presence at what stage of lung development? Canalicular stage

Static Lung Volume

Tidal volume Volume of normal breathing

Vital Capacity Maximal expired volume after maximal

inhalation Inspiratory reserve volume (IRV) + tidal

volume (TV) + Expiratory reserve volume (ERV)

Residual volume Volume remaining after maximal exhalation

Functional residual capacity Expiratory reserve volume (ERV) + residual

volume (RV) Total lung capacity

vital capacity (VC) + residual volume (RV)

Upper Respiratory Tract Infections

Acute Nasopharyngitis “URI”, common colds Average of 3- 8 URI/year Rhinovirus First 2 yrs. of life Fever, irritability, sneezing Differential dx: foreign body obstruction,

allergic rhinitis Otitis media-most common complication

Acute Pharyngitis “tonsillitis, tonsillopharyngitis” Group A b-hemolytic streptococcus 4 – 7 yrs. Old Headache, abdominal pain, vomiting,

petechial mottling of soft palate (strep) Throat swab for strep antigen, throat culture Otitis media- most common complication Penicillin – drug of choice for strep

Retropharyngeal Abscess Complication of Bacterial pharyngitis

Retropharyngeal space - potential space bet posterior pharyngeal wall & prevertebral fascia

Most frequent in children < 3 yr of age Grp A hemolytic strep, oral anaerobes, staph aureus Fever, difficulty of swallowing, drooling Bulging of posterior pharyngeal wall Complication: aspiration of pus Meds: semisynthetic penicillin. Clindamycin, ampicillin-

sulbactam

Sinusitis Maxillary & ethmoid – anatomically present in utero Frontal – develop by age of 1-2 yr Frontal & Sphenoid –radiologically present only at 5-6 yrs

of age Strep pneumonea, moraxella catarrhalis, H. influenzae Cough, nasal discharge – most common symptoms Fever, peri orbital edema, facial pain (+) air fluid level & opacification Complications: meningitis, subdural abscess

Epiglottis “supraglottitis” H. influenza b 2 – 7 yrs old Severe airway obstruction death Inspiratory stridor “tripod sign” Cherry red epiglottis Keep airway patent Meds: cephalosporin

Croup “Laryngotracheobronchitis” or LTB Fever, brassy cough, inspiratory stridor Occurs in young children Mx: steam inhalation, dexamethasone,

racemic epinephrine Contraindicated: opiates or sedatives

Chest X-Ray

The Intensive Course in Pediatric Pulmonology

Acute Laryngotracheobronchitis

Laryngitis Acute Spasmodic Laryngitis

Similar to LTB w/ absent of history of URI Afebrile, barking cough

Acute Infective Laryngitis Caused by viruses Subglottic area – principal site of obstruction Loss of voice

Bacterial Tracheitis Life threathening airway obstruction S. aureus < 3 yrs old Follows an apparent viral infection, measles As complication of intubation Direcr laryngoscopy – pus Mx: intubation/ tracheostomy, antibiotics

Lower Respiratory Tract Infections

Acute bronchitis Gradual onset Preceeded by URTI Fever, conjunctiva injection, rhinitis, dry

hacking, non-productive cough Chest pain, wheezing, rhonchi

Bronchiolitis Respiratory syncytial virus – 50% Occurs during the 1st 2 yrs of life (peak – 6 month of

age) “ball valve” type of obstruction hypoxemia

V/Q mismatch respiratory failure Critical phase – first 48 – 72 hrs Fever. Cough, wheezing, dyspnea CXR – increase AP diameter w/ hyperinflation MX: oxygen, ribavirin (virazole)

Bronchiolitis Obliterans Progressive airways obstruction Inflammation & granulations tissue formation

of small airways Associated with adenovirus infection Common complications of lung transplant May be delayed by corticosteroids

Pneumonia Causative agents: bacteria, virus,

mycoplasma, aspiration Severity: mild, moderate, severe WHO: No pneumonia, pneumonia, severe

pneumonia Location: lobular, lobar, bronchopneumonia

Chest X-Ray

The Intensive Course in Pediatric PulmonologyNormal

Chest X-Ray

The Intensive Course in Pediatric PulmonologyPneumonia

Bacterial Pneumonia Chidren > 2 months of age

Most common microorganisms: S. pneumoniae H. influenzae

Most common symptoms: fever, cough, dyspnea

Children < 2 months old Most common microorganisms: Group b strep E. coli +/- fever Tachypnea - most reliable sign

Pneumococcal pneumonia 90% cases Lobar involvement CXR: lobar consolidation

H. Influenzae pneumonia Insidious onset Predeed by URTI Nosocomial infection no characteristics clinical / radiological patterns

Chest X-Ray

The Intensive Course in Pediatric PulmonologyConsolidation

Staphylococcal pneumonia Occurs in young infants Associated with septicemia, skin infections,

measles Serious, rapid progressive course of illness Extensive bilateral lung involvement CXR: nodular infiltrates, multiple abscesses,

empyema, pneumothorax Meds: penicillinase-resistant penicillin

Chest X-Ray

The Intensive Course in Pediatric PulmonologyStaphylococcal Pneumonia

Klebsiella pneumonia Thick-rusty sputum Bulging of fissures Pulmonary abscess & cavitations

Pseudomonas pneumonia Immunocompromised, debilitating

patients Prolonged mechanical ventilatory support HIV

CXR: presence of necrosis

Case 1 3 y/o F, fever, cough & difficulty of breathing of 3 days duration. PPE:

febrile, alar flaring, stridor, drooling of the saliva. Patient was noted to assume a “tripod” position

Questions: Where is the site of the lesion?

A. URT B. LRT What is the probable diagnosis in this case?

A. pneumonia B. laryngitis C. epiglottitis What are the expected clinical findings?

A. bulging of posterior pharyngeal wall B. cherry red epiglottis C. floppy epiglottis

What is the antibiotic of choice? A. penicillin B. cephalosporin c. ampicillin

Preventive measures is best achieved by: A. vaccination B. primary chemoprophylaxis C. post-exposure antibiotics

Non-Infectious Disorders of the Respiratory Tract

Acquired Allergic rhinitis Epistaxis FB obstruction/ aspiration Nasal polyps Nasal septal

deviation /perforation

Congenital Nasal hypoplasia High arch palate Choanal atresia Laryngomalacia Tracheomalacia Congenital Central

Hypoventilation Syndrome

Congenital

Choanal atresia Unilateral or bilateral bony(90%)or

membranous(10%) septum between the nose & the pharynx

Associated w/ CHARGE syndrome – coloboma, heart disease, atresia choanae, retarded growth & development or CNS anomalies or both; genital anomalies or hypoganadism or both; & ear anomalies or deafness, or both

Dx: inability to pass a firm catheter through each nostril 3 -4 cm into the nasopharnx

Congenital

Laryngomalacia Most common congenital laryngeal abnormality Flabbiness of epiglottis & supraglottic apperture Floppy arytenoid cartilages Short aryepiglottic folds Noisy, crowing respiratory sounds during

inspiration – “Halak” Diagnosed by direct laryngoscopy Resolves spontaneously

laryngomalacia, patient.mpg

BURNS - omega epiglottis.mpg

Congenital Central Hypoventilation Syndrome CCHS (Ondine’s curse)

Primary CNS defect Term, AGA Resp failure, slow & irregular respiratory pauses,

cyanosis appear on the 1st day of life Px fail to respire adequately during sleep, not during

wakefullness No sensitivity to carbon dioxide & hypoxemia No ventilatory response to CO2 during sleep PCO2 to 80 -90 mmHg during sleep

Obstructive Sleep Apnea (OSA)

Upper airway obstruction 2nd to adenotonsillar hypertrophy

Triad: Snoring, noctural breathing difficulty, respiratory pauses

Polycythemia, respiratory acidosis & metabolic alkalosis, RVH

PSG (polysonograph)- diagnostic “gold standard”

Acquired

Epistaxis Kiesselbach’s plexus – most common

location for bleeding Stop spontaneously in most cases Local application of oxymetazoline or

neosynephrine (0.25 – 1 %)

Acquired

Nasal polyps Benign pedunculated tumors formed from

edematous, chronically inflamed nasal mucosa Glistening, gray, grape like masses squeezed

bet the nasal turbinates & septum Cystic fibrosis – most common childhood cause

of nasal polyposis Mx: intranasal steroids, surgical removal

Acquired

Foreign Bodies Location: nose, trachea, bronchus Sudden onset Croupy, barking cough Hoarseness, aphonia (larynx) Recurrent lobar pneumonia, intractable

asthma

Chest X-Ray

The Intensive Course in Pediatric PulmonologyForeign Body Aspiration

2y/o child presenting with chronic cough, bronchiectasis on xray, with digital clubbing

Ballpen tip found in the left lower bronchus of a child with persistent respiratory symptoms & abnormal xray (persistent atelectasis, left lung) Patient subsequently underwent removal of the foreign body via rigid bronchoscopy by the ENT.

National Children’s Hospital 2004

Plant fragments

Royal Children’s Hospital 2008

Aspiration Pneumonia

Predisposing condition Congenital

Esophageal atresia Cleft lip/palate Duodenal obstruction GER

Acquired Debilitated infants Cerebral palsy

Materials commonly aspirated: Milk, cereals, food Vomitus Baby powder Hydrocarbon (Kerosene) Lipoid materials

Medicated oils Cod liver oils

Kerosene Aspiration

Most common in the Philippines Low viscosity, High volatility cough, fever, dyspnea, hypoxemia,

cyanosis Pneumothorax, subcutaneous empysema,

pleural effusion All symptomatic should be admitted for

observation Gastric lavage is contraindicated

Chest X-Ray

The Intensive Course in Pediatric PulmonologyPneumothorax

Chest X-Ray

The Intensive Course in Pediatric PulmonologyPleural Effusion

Kerosene Aspiration

No patient should be sent home in < 6 hrs.

All symptomatic patient should be admitted

Gastric lavage is containdicated

Congenital Lung Anomalies

Lung agenesis Bilateral – incompatible with life

Lung hypoplasia Associated w/ persistent fetal

hypertension & ipsilateral diaphragmatic hernia

Pulmonary Sequestration Mass of non-functioning embryonic &

cystic pulmonary tissue that receives its blood supply from the systemic artery

2 Types: Intralobar Extralobar

Angiogram – “gold standard” diagnostic tool

Chest X-Rays

The Intensive Course in Pediatric Pulmonology

Aortogram

The Intensive Course in Pediatric Pulmonology

Pulmonary Sequestration

Bronchogenic Cysts Abnormal budding of the tracheal

diverticulum of the forgut Lined w/ ciliated epithelium Located at the midline between the

trachea & esophagus or carina Cyst with air-fluid level

Chest X-Ray

The Intensive Course in Pediatric PulmonologyBronchogenic Cyst

Congenital Cystic Adenomatoid Malformation (CCAM) Malformation of the terminal bronchiolar

structure Contains small amount of normal lung tissue w/

many glandular elements Single lobe of one lung is enlarged & often cystic Ipsilateral lung may be hypoplastic Left lower lobe – most common

Congenital Lobar Emphysema Single or multiple lobe Left upper lobe – most common

Tuberculosis in Children

Etiology: mycobacterium tuberculosis Droplet’s inhalation lungs Incubation peroid: 2 - 10 weeks

Tuberculin Test

Mantoux test PPD- RT23 (2-TU PPD-RT23)

WHO & IUATLD 5-TU PPD-S

ATS & CDC

0.1 ml of the 2TU of RT23 will have a tuberculin reactivity similar to 0.1 ml of the 5

TU of PPS-S

Positive PPD > 10 mm induration

Children < 5 yr old BCG immunized children

> 5 mm induration Children > 5 yr old Non-BCG vaccinated children

Accelerated BCG reaction on “BCG test” Induration (at least 5 mm) – 48 – 72 hrs Pustules - 5 – 7 days Healing – 2 – 3 weeks

TB Infection vs. Disease

TB infection (+) tuberculin skin test No sign & symptoms (-) CXR

TB disease (+) tuberculin skin test (+) signs & symptoms (+) CXR

TB Classification

Class I (TB Exposure) (+) exposure to anadult/adolescent w/

activeTB (-) signs & symptoms of TB (-) mantoux tuberculin test (-) chest x-ray

Class II (TB infection) (+/-) history of exposure (+) mantoux tuberculin test (-) signs & symptoms of TB (-) chest radiograph

Class III (TB disease) A child who has active TB has 3 or more of the following

criteria:1. (+) hx of exposure to an adult/adolescent w active TB

disease2. (+) mantoux tuberculin test3. (+) signs & symptoms: one or more of the ff should be

present: Cough/wheezing > weeks; fever > 2 weeks Painless cervical &/or other lymphadenopathy Poor weight gain; failure to make a quick return to normal after

an infection (measles, tonsillitis, whooping cough); failure to respod to appropriate antibiotic therapy(pneumonia, otitis media)

4. Abnormal chest x-ray suggestive of TB5. Laboratory findings suggestive of TB

Class IV (TB inactive) A child/adolescent with or without history

of previous TB and any of the following: (+/-) previous chemotherapy (+) radio logic evidence of healed/calcified TB (+) mantoux tuberculin test (-) signs & symptoms (-) smear/culture for M.tuberculosis

Chest X-Ray

The Intensive Course in Pediatric PulmonologyMiliary TB

Mercado Endo TB.mpg

Management of Newborns of Tuberculous Mothers

Case 1 Mother – TB infection

(+) PPD , No evidence of disease

Baby – give BCG at birth

Case 2 Mother – TB disease

Treatment for 2 weeks or more

Baby – Start isoniazid at birth

- do mantoux test at 4 – 6 weeks PPD (-) continue INH Repeat PPD after 3 months PPD (-) D/C INH, give BCG

PPD (+) CXR (-) INH 6 more months

CXR (+) INH, RIF 6 month PZA 2 month

Case 3

Mother – TB disease, untreated Do not separate the newborn

Baby – at birth – start Isoniazid & rifampicin

- do PPD , CXR PPD (-) CXR (-)

Repeat PPD after 3 month: PPD (-) CXR (-) mother completed TX BCG

PPD (+) CXR (-) continue INH & RIF for 6 more month

PPD (+) CXR (+) continue INH, RIF for 6 more months + PZA for 2

months