Respiratory Diseases

General Introduction
Respiratory diseases that include inflammation
of upper and lower respiratory tract, allergic
diseases, pleura diseases, foreign body,
pulmonary tumors and congenital disorders is
a significant cause of death and chronic illness
in children.
Pediatric pulmonary diseases account for almost 50%
of deaths in children under age 1 year and about 20%
of all hospitalization of children under age 15 years.

General Introduction
Respiratory infections are the most frequently
occurring illness in childhood.
Pneumonia accounts for almost 28% of deaths
in children under age 5 years.
Approximately 7% of children have some sort
of chronic disorder of the lower respiratory
system

Definition
Inflammation of the pulmonary
parenchyma which is more
common in childhood but
occurs more frequently in
infancy and early childhood
Classification
Classified by anatomy
Lobar Pneumonia
Bronchopneumonia
Interstitial Pneumonia
Bronchiolitis
Classification
Classified by etiology
Viral Pneumonia
Respiratory Syncytial Virus (RSV )
Adenovirus
Rhinoviruses
Parainfluenza or influenza viruses
Enteroviruses
Cytomegalovirus (CMV)
Measles virus
Human metapneumovirus
Human bocavirus
SARS coronavirus

About Human Metapneumovirus
It is classified by paramyxovirus.
It is about over 10% of all children with
respiratory infection in winter.
It is nearly not covert infection at all.
It is one of the most important pathogens
that cause the wheeze.
It is mainly cause bronchopneumonia and
bronchiolitis.
About Human Bocavirus
It is classified by parvoviridae.
It is about 1.5~11.3% of all children with
respiratory infection.
It is one of the most important pathogens
that cause the wheeze.
It is mainly cause bronchopneumonia and
bronchiolitis.
Is it a pathogen?
About coronavirus
Type 1 Mammal
Type 2 Mammal
Type 3 Aves
Type 4 SARS Coronaviruses
Classification
Bacterial Pneumonia
Gram-positive coccus
Streptococcus Pneumoniae
Staphylococcus aureus ,CNS!
Gram-negative bacillus
Pneumobacillus
Escherichia coli
Pseudomonas
Haemophilus influenzae
Klebsiella
Legionella pneumophila
Anaerobe

Classification
Mycoplasmal pneumonia
Mycoplasma pneumoniae
Chlamydial pneumonia
Chlamydia
Fungal Pneumonia
Cryptococcus
Candida
Coccidioides
Histoplasma

Classification
Protozoal pneumonia
Pneumocystis Carinii
Noninfectious pneumonia
Inhalation Pneumonia
Eosinophilic pneumonia

Classification
Classified by course
Acute Pneumonia: <1 month
Deferred Pneumonia: 13 months
Chronic Pneumonia: >3 months

Classification
Classified by patients condition
Mild pneumonia
Severe pneumonia

Classification
Others
Typical pneumonia
Atypical pneumonia
Pneumonia caused by SARS coronavirus

Community acquired pneumonia (CAP)
Hospital acquired pneumonia (HAP)


Bronchopneumonia
Introduction
Bronchopneumonia, accounting for 24.5%
56.2% of all hospitalizatons of children, is the
most frequently occurring illness in childhood.
The incidence is higher in early childhood than in
any other period of life.
There are significant difference in the incidence
of bronchopneumonia by season and geographic
region.

Etiology
Most pneumonia in children are caused
by viruses and bacteria.
Viruses
RSV
Parainfluenza viruses (1, 2 and 3)
Influenza viruses (A and B)
Adenovirus
RSV, parainfluenza and influenza are
responsible for more than 75% of cases.
Etiology
Bacteritic
Streptococcus Pneumoniae (the most common
cause of bacterial infection)
Staphylococcus aureus ,CNS
Haemophilus influenzae
Klebsiella
Pneumobacillus
Escherichia coli
Pseudomonas
Mycoplasma pneumoniae

Different organisms affect different age groups

Age Bacterium Virus others
1d-20d Group B H Streptococcus Cytomegalovirus
Gram-negative bacilli(E.coli)


3w-3m Streptococcus pneumoniae RSV Chlamydia trachomatis
Bordetella pertusssis Parainfluenza virus
Staphylococcay aureus

4m-4y Streptococcus pneumoniae RSV Mycoplasma pneumoniae
Haemophilus influenzae Parainfluenza virus
Mycobacterium tuberculosis Influenze virus
Adenovirus
Rhinoviruses

5y-15y Streptococcus pneumoniae Mycoplasma pneumoniae
Chlamydial pneumonice
Etiology
Other causes
Age
Season of the year
Immune status of the host
Environmental factors
Pathology
Inflammatory cell infiltration, exudate, edema
and localized hemorrhage of bronchiolar
submucosa, Interstitium, alveoli, Interalveolar
septa and lymphatic vessels
Necrosis of bronchiolar and alveolar epithelium
Hyperinflation or collapse of the distal lung
tissue
Pathology
Lesions of viral or bacterial infection result in
tracheitis, bronchitis, interstitial pneumonia
and lobuli pneumonia.
Interstitial involvement is relatively common
in viral pneumonia.
Bacterial pneumonia is characterized by the
presence of damages of lung tissue.
Pathophysiology
Respiratory disorder (acute respiratory
failure)
Ventilation and /or perfusion disorder (V/Q
mismatch)
Diffusion defects
Intrapulmonary shunt
Pathophysiology
Circulatory disorders
Viral and/or toxipathic myocarditis
Pulmonary hypertension
Heart failure
Circulatory failure ( shock)
Disseminated intravascular coagulation (DIC)

Pathophysiology
Anomalies of central nervous system
Cerebral edema (toxic encephalopathy)
Hypoxemia
Hypercapnia
Metabolic Acidemia
Energy metabolism disorder
Toxin

Pathophysiology
Anomalies of Alimentary system
Toxic enteroparalysis
Gastrointestinal bleeding
Hypoxemia and hypercapnia
Abnormalities of electrolyte balance
Toxaemia
shock
Acute stress ulcer
Hepatic injury
Pathophysiology
Acute renal failure
Adrenal crisis (insufficiency)
Abnormalities of water, electrolyte
and pH balance


Bronchia mucosa edema
Alveolus edema
air entry
air exchange
Respiratory failure
Metabolic acidosis
Respiratory acidosis
toxic encephalopathy
Gastrointestinal
breeding
Heart failure
Toxic
enteroparalysis
Toxaemia
Clinical Manifestations
Symptoms and sings
General symptoms and sings
Fever
Body temperature is higher in bacterial
infection than viral infection
Hypothermia (infant)
symptoms and sings of generalized toxicity
Myalgia, Malaise and headache
Clinical Manifestations
Symptoms of respiratory system
Cough
Dry cough
Productive cough
Tachypnea
Dyspnea
Rapid, shallow respirations( 4080/ min)
Nasal flaring
Intercostal, subcostal, and suprasternal
retraction
Cyanosis
Respiratory fatigue
Clinical Manifestations
Signs of respiratory system
Widespread moist rales and wheezing
Signs of substantial variations
Decreased breath sounds
Dullness to percussion
diminished tactile or vocal fremitus
Bronchial breath sounds

Clinical Manifestations
Severe Pneumonia
Circulatory system
Rival or toxic myocarditis
Heart failure
Heart failure
Rapid, shallow respirations60/min
Rapid heart rates 180/min
Dyspnea with intercostal and subcostal
retractions, cyanosis, pale and gray of face ,
irritability, and peripheral pallor
Muffled and distant heart sounds, and a gallop
rhythm
Liver enlargement
Edema of the face and extremities,oliguria or
anuria

Clinical Manifestations
Nervous system
Toxic encephalopathy
Alimentary system
Toxic enteroparalysis
Gastrointestinal bleeding
DIC
SLADH
MODS
Complications
Empyema
Pneumothorax
tension pneumothorax
Pyopneumothorax
Pneumatocele

Laboratory Test
Tests for etiologic agent
Bacterial culture
Blood culture
Culture of material from the respiratory
tract secretion
Culture of Pleural effusion
Other culture


Laboratory Test
Laboratory diagnosis of viral infections
Antigen or nucleic acid detection
Isolation of viruses by culture of the
respiratory tract secretions
Use of special antibodies
Laboratory Test
Isolation and culture of other etiologic agent
Mycoplasma pneumoniae
Chlamydia
Fungi
Specific antibody detection on the pathogens
Tests of molecular biology
DNA probs
Polymerase chain reaction (PCR)


Laboratory Test
Blood test
White blood cell counts
Bacterial pneumonia
Rival pneumonia
NBT test
NBT-positive cells>10%
C-reactive protein (CRP)
CRP 15g/ml
Blood gas analysis
Chest X-ray Findings
Perihilar streaking
Increased interstitial markings
Peribronchial cuffing
Patchy infiltrates in the lung
Development of pneumatoceles
Hyperinflation of the lung
Atelectasis
Lobar consolidation (as in bacterial pnuemonia)
Radiographic findings of pleural effusion

Diagnosis and Differential Diagnosis
Diagnosis
According to symptoms, signs, and Radiographic
findings, bronchopneumonia are easily diagnosed.
A key decision in evaluating children with
bronchopneumonia is to determine whether the
illness is mild or severe, or whether a secondary
infection or complication is present
Diagnosis and Differential Diagnosis
Differential Diagnosis
Acute bronchitis
Pulmonary tuberculosis
Acute miliary tuberculosis of the
lungs
Foreign body in bronchus

Acute bronchitis

Acute miliary tuberculosis of the lungs

Acute miliary tuberculosis of the lungs
Foreign body in bronchus
Treatment
General treatment
Humidification of inspired gases
Hydration and electrolyte supplementation
Oral hygiene
Nutrition

Treatment
Etiological treatment
Antibiotic therapy
It is not possible to differential reliably between
bacterial or viral pneumonia on clinical or
radiological grounds ,so all children diagnosed
having pneumonia should be giving antibiotics as
the pathogen is rarely known when treatment is
started.

Treatment
Before the pathogen is identified, therapy
of patients is determined by the pattern of
disease and the organisms that are
common for age of the children .
Community-acquired bacterial
infection
Nosocomial infection acquired in the
hospital
The choice of antibiotic is determined by ages

Age Out-patients In-patients(Intravenous)
(oral) Less severe Severe
1-20d Ampicillin Ampicillin+Cefotaxime
Ampicillin+Cefotaxime

3w-3m Erythromycin Erythromycin Cefotaxime
Azithromycin Erythromycin +Cefotaxime

4m-4y Amoxicillin Ampicillin Cefotaxime
Ceforoxime

5y-15y Erythromycin Erythromycin Cefotaxime
Clarithromycin Azithromycin Cefuroxime
Azithromycin Erythromycin+Ampicillin Cefotaxime+Azithromycin
Azithromycin +Ampicillin Cefuroxime+Azithromycin

Treatment
Oral antibiotics (e.g. co-amoxiclav or a
second-generation cephalosporin such
as cefaclor) can given for less severe
pneumonia.
Treatment
If intravenous therapy is required, activity
against pneumococci, H.influenzae and
Staph aureus can be achieved with a
cephalosporin (e.g. cefotaxime, ceftriaxone,
cefuroxime, cefazidime )
Treatment
Therapy for most patients should be continued
for a total of 57 days after body temperature
is normal, or at least 3 days after clinical
symptoms has disappeared.
The course of treatment for staphylococcus
aureus is usually for 6 weeks
Treatment for Mycoplasmal pneumonia is
usually for 23 weeks.
Treatment
Once the pathogen has been
identified and the antibiotic
sensitivities determined, the most
appropriate drugs should selected.
The choice of antibiotic is determined by organisms(1)
Organisms First choice Second choice
Strept pneumoniae Pnicillin G Ceftriaxone
Cephlosporins Cefotaxime
(1st or 2nd generation) Vancomycin

H. influenzae Amoxicillin+Clav Acid Cephlosporins
Amoxicillin +Sulbactam (1st or 2nd generation)
Macrolides
(New generation)

Staphylococeus MSSA MSSE Oxacillin Cephlosporins
Claxacillin (1st or 2nd generation)
MRSA MRSE Vancomycin
Rifampine

M.catarrhalis Amoxicillin+Clav Acid Macrolides
(New generation)
Cephlosporins
(1st or 2nd generation)
The choice of antibiotics is determined by organisms(2)

Organisms First choice Second choice
Enteric bacilli Ceftriaxone Ticarcillin+Clavulanic Acid
(+Amikacin) Azfreonam
Cefotaxime Imipenem
4th generatim Cephlosporins

P.aeruginose Ticarcillin+Clav.Acid AMK+Azfreonam
Piperacillin+TAZ Imipenem
Mezlocillin
Ceflazidime
Cefoperazone+Sulperazon
Cefepime+AMK

GBS Penicillin G(LD)
Amoxicillin
Ampicillin

Treatment
If staphytococcal aureas or CNS
pneumonia is suspected, Penicillin,
Clindamycin, Vacomycin (one of
them ) is given.
Treatment
If M.pneumoniae or
Ch.trachomatis pneumonia is
suspected, erythromycin is given.
Treatment
Anti-viral therapy
Ribavirin
Interferons
Poly I:C
Treatment
Heteropathy
Oxygen therapy
Maintaining free airway
Treatments for heart failure
Treatments for toxic enteroparalysis
Treatments for respiratory failure
Treatments for shock
Treatments for toxic encephalopathy


Treatment
Treatments for heart failure
Oxygen inhale
Sedation
Cardiotonic
Diureses
Drugs of dilating blood vessel

Treatment
Treatments of toxic encephalopathy
Oxygen inhale
sedation
Pyretolysis
Subhibernation
Anhydration
20%Mannitol 1.5~5ml/kg /does
q6h

Treatment
Application of cortical hormone
Indication
Severe pneumonia
Superhigh fever
Severe toxic symptoms
Wheezing
Shock, toxic encephalopathy, Cerebral
edema, and respiratory failuer
pleural effusion

Treatment
Treatments for complications
Repeat pleural taps for remove
of pleural fluid
Clinical Teafures of Pneumonia
due to Some Pathogen
Rspiratory syncytial virus pneumonia
Adenovirus pneumonia
Staphylococal aureus pneumonia
Gram-negative bacillary pneumonia
Mycoplasma pneumonia
Chlamydial pneumonia
Respiratory snycytial virus pneumonia
Diffuse wheezing and tachypnea following
upper respiratory symptoms in an infant
(age one year).
Epidemics in late fall to early spring .
Hyperinflation on chest X-ray.
RSV antigen detected in nasal secretions.
30%-40% of patients hospitalized with this
infection will wheeze later in childhood.
Adenovirus pneumonia
Severe pneumonia may occur at all ages. It is
especially common in young chillren (age
6months~2years).
Chest X-rays show bilateral peribronchial and
interstitial infiltrates.
Symptoms include high fever, respiratory
symptoms, diarrhea, encephalitis, hepatitis and
myocarditis may persist for 2-3weeks.
Can be necrotizing and cause permanent lung
damage, especially bronchiectasis.
Staphytococcal aureus pneumonia
This pneumonia is characterized by abdominal distention,
high fever, respiratory distress, and toxemia.
It often occurs without predispossing for factors or after
minor skin infections.
Pneumotoceles, pyopneumothora, and empyema are
frequently encountered.
Rapid progression of disease is characteristic.
Frequent chest X-rays to monitor the progress of disease are
indicated.
WBC
Myeoplasma pneumoniae pneumoia
Essentials of diagnosis typical festures:
Fever
Cough
Appropriate age:over5year
Endemic and epidemic infection can occur.
The incubation period is long(2-3weeks).and the
onset of symptoms is slow.
Extrapnlmonary complications sometimes occur.
Chest X-rays usually demonstrate interstitial or
bronchopneumonia infiltrates, frequently in the
middle or lower lobes.

Chlamydial pneumonia
Cough, tachypneu, rales, few, wheezes, and
no fever.
Appropriate age:2~12weeks.
Inclusion conjunctivitis, eosinophilia, and
elevated immunoglobulins can be seen.
Chest X-rays may reveal diffuse interstitial
thickening, or focal consolidation.
Avian influenza in human beings
Due to the infection of HPAI virus ( highly
pathogenic avian influenza ,type H5N1).
Characteristic syndrome of sudden onset of
high fever,severe myalgia, headache and
chills.
Diarrhea, vomiting, and MOF, DIC are
common.
High case fatality rate (over 30%~67%)
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