Professional Documents
Culture Documents
TOPIC OUTLINE
I. Anatomy and physiology of the respiratory tract
II. Common respiratory problems in children
A. Infectious disorders
1. acute upper respiratory infections
rhinitis
sinusitis
otitis externa/media
acute tonsillopharyngitis
2. acute laryngitis
3. bronchitis
4. bronchiolitis
5. pneumonias
Course Content: (cont.)
B. Non-infectious disorders
foreign bodies
atelectasis
Asthma
C. Pulmonary tuberculosis
primary infection
progressive primary infection
multidrug resistant pulmonary tuberculosis
miliary tuberculosis
Fetal Lung Development
embryonic
7-16 weeks: formation
of the bronchial tree
17-24 weeks: primitive
gas exchange surface
forms
24-40 weeks: alveolar
development continues
35 weeks: stable
surfactant production
5 Stages of LUNG development
EMBRYONIC: week 4 - 5
PSEUDOGLANDULAR: week 5 16
CANALICULAR: week 16 25
SACCULAR: week 24 40
ALVEOLAR: late fetal - 8 years
STAGES OF LUNG DEVELOPMENT
Type II fibers
fast-twitch and low-oxidative
have high contractility but are more prone to
fatigue.
The proportion of type I fibers in the
diaphragm and intercostals of
premature infants is only around 10%.
This increases to around 25% in full-
term newborns and around 50% in
children >2 years.
Respiratory muscles of premature
babies and young infants are therefore
more susceptible to fatigue, resulting in
earlier decompensation.
Overall, the pediatric airway being smaller,
has poorly developed cartilaginous
integrity allowing for more laxity
throughout the airway.
ANATOMY PEDIATRIC ADULT
extrathoracic airway
from the nose to the thoracic inlet
intrathoracic-extrapulmonary airway
from the thoracic inlet to the main stem bronchi
intrapulmonary airway
within the lung parenchyma
valuable signs in localizing the site of
respiratory pathology
Intrapulmonary airway
Rapid and shallow respirations (tachypnea)
Grunting
GRUNT
is produced by expiration against a partially
closed glottis
is an attempt to maintain positive airway
pressure during expiration
most beneficial in alveolar diseases that
produce widespread loss of FRC, such as in
pulmonary edema, hyaline membrane
disease, and pneumonia
INTERPRETING THE CLINICAL SIGNS OF
RESPIRATORY DISEASE
Tachypnea + + +++
Retractions ++++ ++ ++
Stridor ++++ ++
Wheezing ? +++ ++
Grunting ? ? +++
DIAGNOSTIC PROCEDURES
CBC not very reliable
Cultures if (+) exudates
Chest radiographs
In infants and young children ( AP-Lateral
views)
Why? Lesions in the hilar areas maybe
obscured by the cardiac silhouette
ABG
RESPIRATORY DISORDERS
RHINITIS
is a viral illness
prominent symptoms:
rhinorrhea (nasal discharge)
nasal obstruction
Common cold
P.E. limited to the upper respiratory tract
Mode of transmission:
by aerosols
Small particle (Influenza virus)
Large particle
direct contact (Rhinoviruses and RSV)
rhinorrhea antihistamines
Complications:
Otitis media most common
Bacterial sinusitis
should be considered if rhinorrhea or daytime
cough persists without improvement for at
least 10-14 days or if signs of more-severe
sinus involvement such as fever, facial pain,
or facial swelling develop.
Exacerbation of asthma
PREVENTION
Chemoprophylaxis or immunoprophylaxis is
generally not available for the common cold.
Vitamin C and echinacea DO NOT prevent the
common cold.
Intracranial complications:
Meningitis
cavernous sinus thrombosis
Abscess
Subdural empyema
OTITIS EXTERNA
Precipitating factors;
Trauma
Swimming
Impacted cerumen
Change from the normal acid to alkaline
pH of the external auditory canal
OTITIS EXTERNA
Etiology: Staph aureus (most common)
Others: gram negative bacilli
(Pseudomonas aeruginosa, Proteus
vulgaris, E. coli)
s/s: ear pain aggravated by movement of
the tragus
hearing is normal
TREATMENT
Cleansing and drying of External Auditory
Canal
If (+) infection: DO NOT irrigate
If (+) cellulitis and chondritis: Rx antibiotic
OXACILLIN or any penicillinase-resistant
penicillin
OTITIS MEDIA
Inflammation of the mucoperiosteal lining of the
eustachian tube, tympanic cavity, mastoid
antrum and mastoid air cell system
OTITIS MEDIA
Peak incidence: 1st 2 yrs
Three pathogens predominate in OM:
Streptococcus pneumoniae (most common)
Haemophilus influenzae
Moraxella catarrhalis
Predisposing factors of developing
otitis media in children:
developmental alterations of the Eustachian
tube (short, wide, & straight)
an immature immune system
frequent infections of the upper respiratory
mucosa
the usual lying-down position of infants favors
the pooling of fluids, such as formula.
Symptoms of AOM are variable, especially
in infants and young children.
In young children, evidence of ear pain
may be manifested by irritability or a
change in sleeping or eating habits and
occasionally, holding or tugging at the ear
Diagnosis: confirmed by otoscopy (TM)
Findings: injection of TM
absent light reflex
decreased motility
retraction or bulging of TM
Otitis media
Amikacin, 15mg/kg/24hrs
Chronic OM
ACUTE PHARYNGITIS
Sore throat
Pharyngitis: Etiology
A) Viral: Most common
Rhinovirus (most common).
Symptoms usually last for 3-5 days.
B) Bacterial: Group A beta hemolytic
streptococcus (GABHS)
Early detection can prevent complications
like acute rheumatic fever and post
streptococcal GN.
Pathogenesis
Colonization of the pharynx by GABHS
can result in either asymptomatic carriage
or acute infection.
The M protein is the major virulence factor
of GABHS and facilitates resistance to
phagocytosis by polymorphonuclear
neutrophils
Pharyngitis: signs and symptoms
Rapid onset
absence of Cough
Fever
Sore throat
Malaise
Rhinorrhoea
Classic triad of GABHS:
High fever
tonsillar exhudates
ant. cervical lymphadenopathy
Streptococcal pharyngitis
Physical examination:
red pharynx
enlarged tonsils with yellow blood-
tinged exudate
petechiae on the soft palate and
posterior pharynx
enlarged/tender anterior cervical lymph
nodes
Streptococcal pharyngitis
Pharyngitis: Treatment
early antibiotic therapy hastens clinical
recovery by 12-24 hr
RX: penicillin
amoxicillin
Strep. pharyngitis
Clindamycin (20mg/k/day) -
recommended for carriers
DIAGNOSIS
PE: Tonsillar exudates, anterior cervical
lymphadenopathy
Rapid strep: Throat swab. Sensitivity of 80%
and specificity of 95%.
Throat culture - Not required usually. Needed
only when suspicion is high and rapid strep is
negative
Complications
include :
local suppurative complications, such as
parapharyngeal abscess, and later
nonsuppurative illnesses, such as acute
rheumatic fever and acute
postinfectious glomerulonephritis
ACUTE TONSILLITIS
Etiology
Tonsillitis often occurs with Pharyngitis.
Viral or bacterial
ACUTE TONSILLOPHARYNGITIS
R ~ 8l / r4
R resistance, l length, r radius
Severe Croup
Humidified high concentration oxygen
Nebulized racemic epinephrine
Anticipate need to intubate, assist ventilations
EPIGLOTTITIS
Complete Airway
Obstruction
Epiglottitis: Incidence
Respiratory distress+
Sore throat+Drooling =
Epiglottitis
Epiglottitis: Management
High concentration oxygen
Do not attempt to visualize airway
Epiglottitis
chronic bronchitis,
pneumonia,
asthma,
bronchiectasis
BRONCHIOLITIS
viral disease ( RSV >50% )
more common in boys, in those who have
not been breast-fed, and in those who live
in crowded conditions.
Incidence: Children < 2 years old
80% of patients < 1 year old
Bronchiolitis: Pathophysiology
bronchiolar obstruction with edema,
mucus, and cellular debris and air trapping
Resistance in the small air passages
during both inspiration and exhalation
Bronchiolitis: Pathophysiology
BUT because the radius of an airway is
smaller during expiration
the resultant respiratory obstruction
leads to early air trapping and overinflation
If obstruction becomes complete, trapped
distal air will be resorbed develop
atelectasis.
Bronchiolitis: Signs/Symptoms
hyperinflation
bilateral interstitial
infiltrates
peri-bronchial
cuffing
Bacterial pneumonia - consolidation
Diagnosis -Pneumonia
Definitive diagnosis - isolation of
microorganism
blood culture is positive only in 10-30% of
cases
sputum culture - no clinical use
TREATMENT
For mildly ill children who do not require
hospitalization:
amoxicillin is recommended
In communities with a high percentage of
penicillin-resistant pneumococci, high doses
of amoxicillin (80-90 mg/kg/24 hr) should be
prescribed.
Therapeutic alternatives : cefuroxime
axetil and amoxicillin/clavulanate.
TREATMENT
For school-aged children and in children in
whom infection with M. pneumoniae or C.
pneumoniae : a macrolide antibiotic such
as azithromycin
In adolescents: a respiratory
fluoroquinolone (levofloxacin) may be
considered as an alternative
When to hospitalize?
FACTORS SUGGESTING NEED FOR
HOSPITALIZATION OF CHILDREN WITH
PNEUMONIA
Age <6 months
Sickle cell anemia with acute chest syndrome
Multiple lobe involvement
Immunocompromised state
Toxic appearance
Moderate to severe respiratory distress
Requirement for supplemental oxygen
Dehydration
Vomiting or inability to take oral fluids and medications
No response to appropriate oral antibiotics
Social factors
Complication of Pneumonia
Due to direct spread of bacterial
infection within the thoracic cavity
Pleural effusion
Empyema
Lung abscess