Respiratory System

Dr. Shreedhar Paudel17/03/2009

A Clinical Case

• A mother brings her 9 months old baby to ER with the complain of fever and fast breathing for 3 days.– On examination- temperature is 102 degree F, RR

is 65/min, sub-costal indrawing is present, dull on percussion over right chest but no abnormal sound heard on auscultation.

– What is your provisional diagnosis?– What should be your next step?

Pneumonia

• Previously known as pneumonitis

• Inflammation of parenchyma of lungs

• Pathologically– consolidation of alveoli & infiltration of interstitial tissue with inflammatory cell

Classifications

• Simple Classification--Community Acquired--Hospital Acquired

• Etiological Classification--Chemical Pneumonia eg- ingestion of

kerosene--Aspiration Pneumonia eg-vomiting,

aspiration

Etiological Classification contd…..

• Viral Pneumonia--RSV, Adeno virus, Influenza, Parainfluenza

• Bacterial Pneumonia--Pneumococcus, Staphylococcus, H. Influenzae,

Streptococcus, Klebsiella

• Atypical Pneumonia--Chlamydia, Mycoplasma, Pneumocystis carinii

Etiological Classification contd…..

• Fungal Pneumonia--Histoplasmosis--Coccidiomycosis

• Metazooal--Ascaris as in Loeffler’s Syndrome

• Hypersensitivity

Etiology is different depending on the age

• <2 months--Group B Streptococci

• 2 mo-5 yrs--H. influenzae--Streptococcus pneumoniae

• >5 years--Mycoplasma pneumoniae

Note! No one can differentiate the type of

pneumonia just by looking at the patient with 100% sensitivity & specificity

WHO Classification of Pneumonia

• No pneumonia• Pneumonia• Severe pneumonia• Very severe pneumonia

– Important to manage pneumonia cases in communities of developing and underdeveloped countries!

Clinical features

• Symptoms--Cough→ entry point ( all patient will have)--Fast breathing , breathlessness--Excessive crying--Acute abdominal emergency →rarely in case

of basal pneumonia due to referred pain from pleura--High fever--Diarrhoea

Symptoms contd…

--Headache--Pain in shoulder → drooping of shoulder--Meningism ( If upper lobe involved )

↓rigor, convulsionlethargyheadacheneck stiffness

--Turning blue

Clinical signs

• Vitals:--Temperature: ↑--Respiratory Rate: ↑--Blood Pressure: Normal or↓ if in septic

shock after pneumonia– detected by capillary refilling time (CRT)

• Rigor, Cyanosis• Chest signs

Chest signs contd…..

• Inspection—Indrawings; diminished movement or expansion on the side affected; Rash (if any infection)

• Palpation--↑vocal resonance

• Percussion—Dull on the affected side

• Auscultation—Basal crepitations to wheezing (during expiration)– usually B/L(if U/L– Asthma)

Cut off of fast breathing for the diagnosis of pneumonia

AGE RR/Min< 2 months 60 or more2mo-11mo 50 or more12mo-5yrs 40 or more

Eg, in a 3 year old – cough and fever with RR-50/min↓

pneumonia ( no need of steths)

Investigations• CXR—may not have any changes in early disease.

--findings depend on the causative organism

Causative org. X-ray changesViral Over inflationStreptococcal Hyaline patternChlamydial OverinflationStaphylococcal Localized

consolidationPrimary TB Peripheral

infiltrationSec TB Milliary pattern

X-Ray Feature of Pneumonia

X-Ray Feature of Pneumonia contd….

• LobarPneumonia

This chest x-ray shows cloudiness throughout the lungs, caused by acute pneumonia following chickenpox. Pneumonia, as a complication of chickenpox, rarely occurs in children, but occurs in about one-fifth of adults.

Investigations contd…..

• Blood count--↑ WBC (leucocytosis)--Toxic granules & shift to the left ( immature cells→

means infection is very severe so cells are produced very fast)

• Blood culture--positive in 5-15% of cases

• Sputum gram staining & culture

Investigations contd…..

• C-Reactive Protein--↑Acute phase reactant

• ABG (Arterial Blood Gas) Analysis--done in severe cases--Acidosis

Management of PneumoniaClinical Signs Classif

y AsTreatment

•Central Cyanosis•Unable to drink

Very severe Pneumonia

•ADMIT•Oxygen(Central cyanosis, restlessness, grunting, severe indrawing)•Antibiotic(chloramphenicol)•Treat fever & wheezing if present•Supportive care(fluid,food,temp)•Reassess twice daily

•Chest indrawings•Able to drink•No central cyanosis

Severe Pneumonia

•ADMIT•Antibiotic(Benzylpenicillin)•Treat fever & wheezing if present•Supportive care•Reassess daily

Management of Pneumonia…….

Clinical Signs

Classify As

Treatment

•Fast breathing•No chest indrawing

Pneumonia •Home Care•Antibiotic(Amoxycillin, Ampicillin, Cotrimoxazole, Procaine penicillin)•Treat fever & wheezing if present•F/U in 2 days(earlier if worsening)

•No chest indrawing•No fast breathing

No Pneumonia: Cough or Cold

•Home Care•Treat fever & wheezing if present•Assess for the cause of chronic cough

Reassessing the child with Pneumonia

• If getting worse—not able to drink --increased chest indrawings --signs of very severe disease↓

examine for complications and switch to Cloxacillin and Gentamycin if Staph. pneumoniae is suspected.

• If not improving—but no signs of severe disease↓

switch antibiotics from 1st line →2nd line

Oral Antibiotics for Pneumonia

• 1st line : Cotrimoxazole—х2 х5 days

• 2nd line : Amoxycillin– х3 х5 days

NOTE!• Fever is controlled with paracetamol—child with ↑RR which

is even increased by fever may go to respiratory failure• Never cold sponge a child with pneumonia-- ↑crying &

oxygen requirement-- ↑RR—respiratory failure

Contd…..

• Never prescribe steroids as it ↓immunocompentency

• Cough syrup– DEATH prescription

• Calorie & fluid—child is dehydrated--mother—sips of fluid--if iv fluid—give 1/3rd of total requirement (children

with pneumonia may have inappropriate ADH –pulmonary edema, cardiac failure & respiratory failure)

Complications of Pneumonia

• Pulmonary--collapse--lung abscess & rupture--pneumatocele--delayed resolution

• Pleural--fibrinous pleurisy & adhesions--pleural effusion ( less likely)--empyema--pneumothorax (Staph pneumoniae)

Contd…

• Airway--Bronchiectasis—cough (foul smelling)--ottitis media--sinusitis--bronchopleural fistulas

• Cardiac--pericarditis/myocarditis (mortality very high)--pericardial effusion--endocarditis--shock

Contd….

• Cardiac contd…--arrythmias--pulmonary edema--CCF

• Extrathoracic--septecimia--herpes labialis--metastatic infection (meningitis,arthritis, osteitis,

peritonitis)

Contd…

• Toxic & metabolic--Acidosis--acute hemolytic anaemia--febrile convulsions--SIADH

• 1 and ½ yr old M child presented in the middle of the night with noisy breathing

--parents were afraid & it increased when child was excited

O/E—running nose --100 F temp --no chest indrawing --non toxic --RR not increased

Acute laryngotracheobronchitis(CROUP)

• Commonest form of acute upper airway obstruction

--usually viral, bacterial infection may occur

--usually subside within 48 hrs

Causative organisms

• Parainfluenza virus types 1, 2 & 3 are the most important infectious agents

• influenza virus type A & B, respiratory syncytial virus, adenovirus, rhinovirus and enteroviruses are also common

• herpes viruses and bacteria like Haemophilus influenza type B and Staphylococcus aureus –rare cases

Clinical Features

• Usually starts with rhinorrhoea, sore throat, and mild fever for few days

• Then develops the characteristic barking cough, hoarseness,respiratory distress, and inspiratory stridor, with or without the persistence of the low-grade fever

• Symptoms tend to be worse at night but child is usually not acutely ill

Clinical Features contd….

• Drooling is not common in viral croup• Agitation & crying aggravate the symptoms

Note!--incidence of viral croup peaks in the winter

months--91% of cases occur in less than 5 years of age--most cases occur before 2 years--slight male preponderance

Investigations

• Complete blood picture --mild leucocytosis and lymphocytosis(very non-specific)( does not help the diagnosis and will not alter the management--painful procedure and should be avoided)

• Arterial blood gas --only in very severe or intubated cases

• Lateral neck radiograph --not necessary in obvious case (may be considered in stable patients with suspected foreign body or anatomical abnormalities)"steeple sign"

Steeple sign

Steeple sign

Management

• Mild cases--managed in out patient clinic (provided signs of deterioration can be watched out for)-- increasing stridor, increasing respiratory distress and increasing fatigue.

• A calm and warm environment, minimal disturbance together with parenteral comfort is all that needed in most cases of the mild croup.

Management contd…

• Corticosteroids --effective in reducing acute symptoms in moderate to severe cases(Oral administration is as effective as parenteral)

• Nebulizer Steroid Therapy --as Efficient as Systemic Steroid in Reducing Acute Symptoms

Other Supportive Management

• 1) Oxygen --Routine oxygen supplement is not necessary

--given if the child has progressive tachypnoea, tachycardia, cyanosis and laboured breathing

• 2) Fluid--Maintain hydration by encouraging oral fluid intake

-- iv fluid supplement --very distress child. --Over-hydration should be avoided.

Other Supportive Management contd…

• Intubation --rarely needed but act if necessary• Routine chest physiotherapy is not

recommended-- may also aggravate the already distressed child.

• Humidified Air • Antibiotic is not recommended unless

bacterial infection is clinically likely to be present.

Respiratory disorders contd…

Dr Shreedhar Paudel18/03/2009

• Two years old child presented in ER with increased respiartory rate and Increased temperature, looks toxic and there is drooling of saliva from the mouth

What is the diagnosis?

Acute Epiglottitis

“A very rapidly progressive infection causing inflammation of the epiglottis (the flap that covers the trachea) and tissues around the epiglottis that may lead to abrupt blockage of the upper airway and death”

Causative organism• Usually Bacterial in origin

--Hemophilus influenzae (commonest)--Streptococcus pneumoniae--Staphylococcus aureus--Streptococci

Incidence has decreased secondary to Haemophilus influenzae immunization

Symptoms of Epiglotitis Abrupt and rapid onset of

• Sore throat (may refuse to eat)• High fever• Breathing changes

– Breathing difficulty– Open mouthed breathing– Breathing with tongue out– Stridor (Noisy breathing)

Symptoms of Epiglotitis contd..

• Cough—sometimes• Excess saliva secretion • Drooling( 80% of patients)• Voice changes

“clinical triad of drooling, dysphagia, and distress is the classic presentation”

Signs of Epiglotitis• Patient appears acutely ill, anxious• Assumes characterstic TRIPOD sign if old

enough to do so (child to lean forward and hyperextend the neck to enhance air exchange)

• Rapid pulse• Cyanosis• older child, pain may be noted on movement

of the hyoid bone

“Acute epiglotitis is a paediatric emergency”

• Do not--panic--alarm the parents or child--examine the child in any way -

especially do not try to visualize the epiglottitis using a tongue depressor (provoke spasm and cause obstruction)

Do’s

• Call a senior anaesthetist, paediatrician and ENT surgeon in case required

• Minimise distress to the child - don't separate from parents

Investigations

• Securing an airway is the overriding priority. All further evaluations should follow

• CBC—leucocytosis

• Blood cultures and culture of the epiglottis –only after airway secured

Investigations contd….• Blood cultures are positive in less than 15% of

cases caused by H influenzae. • Epiglottic cultures are positive in 50% of cases

caused by H influenzae• Lateral cervical X-Ray—swelling of the

epiglottis (THUMB sign)• Diagnostically radiology is rarely required, and

delaying treatment in order to image the child is inappropriate

Differential diagnosis

• Bacterial tracheitis

• Foreign body trachea

• Anaphylaxis

• Retropharyngeal abscess

Management• Confirm immunization status• Admit to ward if

--stridor at rest--inability to take fluid--respiratory distress

• If child is in respiratory distress--Oxygen supplementation--Tracheostomy if needed--Nebulised vapour may be useful

Management contd….

• Open iv line (as child can’t take orally)-maintain adequate hydration

• Antibiotics—Ceftriaxone (drug of choice for H. influenzae)—chloramphenicol is also equally effective

• 6/12 yrs, M child presented in the month of January with

--noisy breathing--wheeze( with chest indrawing)--100 F temp--past h/o running nose for few days-- very irritable--↑ RR

On examination--B/L Ronchi & crepetations

Bronchiolitis

• Inflammation of the small passages in the lungs (bronchioles), usually caused by a viral infection

• As these airways become inflamed, they swell and fill with mucus, making breathing difficult.

• occurs during the fall and winter months.

Bronchiolitis……

                                                              

Air travels into the lungs via the windpipe (trachea), down

Bronchiolitis…..• most often affects infants and young children

because their small airways can become blocked more easily than those of older kids or adults

• typically occurs during the first 2 years of life, with peak occurrence at about 3 to 6 months of age

• is more common in males, children who have not been breastfed, and those who live in crowded conditions, day-care centers.

Causative organisms

• RSV (Respiratory Synctial Virus)—commonest• Adenovirus• Influenza virus• Parainfluenza virus

“Transmission-- Droplet”

Risk factors• Being exposed to cigarette smoke

• Being younger than 6 months old

• Living in crowded conditions

• Never being breastfed

• Prematurity (born before 37 weeks gestation)

Symptoms• Cough, wheezing, shortness of breath, or

difficulty breathing –opening symptoms• Other symptoms

– Fever – Cyanosis – Grunting – Vomiting, especially post-tussive – Irritability – Poor feeding or anorexia

Signs

• Tachypnea, often at rates over 50-60 breaths per minute (most common physical sign)

• Tachycardia • Fever, usually in the range of 38.5-39°C • Mild conjunctivitis or pharyngitis • Diffuse expiratory wheezing • Nasal flaring

Signs contd….• Intercostal retractions • Cyanosis • Inspiratory crackles • Otitis media • Apnea, especially in infants younger than 6

weeks • Palpable liver and spleen from hyperinflation

of the lungs and consequent depression of the diaphragm

Differential diagnosis

• Asthma • Bronchitis• Pneumonia• Foreign body inspiration• Congestive hear failure

Investigations

“Rarely required for the diagnosis”• Chest X-Ray--↑ed lung markings

--flattening of diaphragm

• Pulseoximeter to measure oxygen levels

• Blood count—usually not helpful

Treatment

“Sometimes no treatment required”• Oxygen— “only drug” (bronchodilators useless)• Adequate hydration and calorie—IV drip but

with caution if SIADH (give 1/3rd of total requirement)

• Wait and watch“After around 3 days the illness subsides”

Treatment contd….

• Sometimes Rivabirin (nebulized)—in literatures—50% success rate

• Severe cases—Digoxin (in view of possibility of CHF)

• Respiratory acidosis if present—correction

Remember

• No anti cough mixture & antibiotics—worsens—death

• Never use nebulized vapour—as vapourized particles increase the obstruction in the bronchioles that have narrowed.

Thank You