Respiratory System (3)

DR.HUSSAM ALDAOUKI
 Lower respiratory tract
infections
 Lower respiratory tract infections (LRTI) are common in
children.
 They include bronchiolitis, bronchitis and pneumonia.
 About half of all cases are viral in origin.
 Around 1 in 3 children in the UK develop bronchiolitis during
their first year of life.
 After 12 months of age approximately 3 in 100 children per
year will have a LRTI.
 Acute Bronchiolitis
 Bronchiolitis is the most common serious respiratory infection of infancy,
 resulting in admission to hospital of 2%–3% of all infants during annual winter epidemics;
 It is the most common cause of RD & acute wheezing in infants resulting from
 inflammatory obstruction of the smali airways (bronchioles)
 Age: 1ST 2 yrs of life (Infancy), with peak incidence at1-9 months IN 90 % (Winter)
 Etiology : A) Viral: Respiratory syncytial virus (> 80% of cases), parainfluenza virus, rhinovirus,
adenovirus, influenza virus, and human metapneumovirus.
B) Others: Mycoplasma
 There is evidence that co-infection with more than one virus, particularly RSV and human
metapneumovirus, may lead to a more severe illness.
 Acute Bronchiolitis
 Pathophysiology
- Virai infection -> Inflammation of the small airways + Obstruction (Edema & mucus)
- Obstruction is more during expiration --> Expiratory wheezes
- Ventilation / Perfusion mismatch
 Acute Bronchiolitis
 C/P :
A) Symptoms
.History of contact with a family member with minor respiratory illness
. Development of nasopharyngitis (3-4 days before the onset)
. Cough, wheezing, dyspnea, RD, irritability following URT symptoms
. Apnea in infants < 6 month
. Risk factors for severe disease: age < 12 wks, GA < 35wks, BPD,CHD
B) Signs
. RD (Grades 1-4)
. Expiratory wheezes
 Acute Bronchiolitis
 Investigations
 Pulse oximetry should be performed on all children with suspected bronchiolitis.
 No other investigations are routinely recommended.
 In particular, chest X-ray or capillary blood gases are only indicated if respiratory failure
is suspected.
. CBC: Normal
.CXR: Hyperinflation
. Nasopharyngeal wash: for RSV antigen detection (Sensitivity :90%)
 Acute Bronchiolitis
 Indication of Hospital admission :
 • apnea (observed or reported)
 • persistent oxygen saturation of <92% when breathing air
 • inadequate oral fluid intake (<70% of usual volume)
 • severe respiratory distress – grunting, marked chest recession, or a respiratory rate
over 70 breaths/minute
 Acute Bronchiolitis
 Treatment
 This is supportive.
 Humidified oxygen is delivered via nasal cannulae or head box at a concentration
adjusted according to pulse oximetry. The infant is monitored for apnoea.
 There is no evidence of benefit from the use of mist, nebulized hypertonic saline,
antibiotics, corticosteroids or bronchodilators such as salbutamol or ipratropium.
 Fluids may need to be given by nasogastric tube or intravenously
 non-invasive respiratory support with continuous positive
 airway pressure (CPAP), bilevel positive airway pressure (BiPAP) or mechanical
ventilation is required.
 Acute Bronchiolitis
 Prognosis
 Most infants recover from the acute infection within 2 weeks.
 However, as many as half will have recurrent episodes of cough and wheeze
 Rarely, following adenovirus infection, the illness may result in permanent damage to
the airways (bronchiolitis obliterans).
 Acute Bronchiolitis
 Preverntation :
 RSV is highly infectious,
 infection control measures, particularly good hand hygiene, cohort nursing, and
 gowns and gloves, have been shown to prevent crossinfection to other infants in
hospital.
 A monoclonal antibody to RSV (palivizumab) given monthly by intramuscular injection
reduces the number of hospital admissions in high-risk preterm infants.
 Its use is limited by cost and the need for multiple injections
 Pneumonia
 - Inflammation of the lung parenchyma
 - Recurrent pneumonia: > 2 attacks in 1 year or > 3 attacks ever
 The incidence of pneumonia peaks in infancy and old age, but is relatively high in
childhood.
 It is a major cause of childhood mortality in low- and middle-income countries
 More than 600,000 children die each year from pneumonia
 worldwide. Viruses are the most common cause in young children beyond the
neonatal period,
whereas bacteria are more common in neonates and older children.
 In clinical practice, it is difficult to distinguish between viral and bacterial pneumonia
 More than half of cases no causative pathogen is identified
 Pneumonia
 Etiology :
 The likely pathogen varies according to age:
 • Newborn – organisms from the mother’s genital tract, particularly group B
streptococcus, but also Gram-negative enterococci and bacilli.
 • Infants and young children – respiratory viruses such as RSV are commonest.
Bacterial infections include Streptococcus pneumonia, H. influenza and
Staphylococcus aureus. Bordetella pertussis and Chlamydia trachomatis can also
cause pneumonia at this age.
 • Children over 5 years – Mycoplasma pneumoniae, Streptococcus pneumoniae,
and Chlamydia pneumoniae are the main causes.
 • At all ages Mycobacterium tuberculosis should be considered.
 Etiology of Pneumonia
 Etiology :
 The likely pathogen varies according to age:
 Pneumonia
 Etiology :
 A) Bacterial:
1. Gram +Ve: Streptococcus pneumoniae, Staphylococci, Streptococci
2. Gram -Ve: Hemophilus influenza, Klebsiella, Pseudomonas
3. TB, Mycoplasma
 Viral:
1. Common: RSV, adenoviruses, parainflvenza, influenza
2. Less common: Rhinovirus, enterovirus, HSV, CMV, measles, variceila
 Fungal : Histoplasma, Aspergilius, Crypto coccus, Pneumocysti s j iro vecii
 Parasitic: Ascaris ,Rickettsial
 Other causes (Non-infectious
 Pneumonia
 Classification
A) Anatomical:
1. Lobar pneumonia ,
2. bronchopneumonia or
3. Interstitial pneumonia
B) Etiological:
1. lnfectious
2. Noninfectious :( Aspiration pneumonia ,Hypostatic pneumonia: Lying in one
position for long time (lung congestion & edema), Hypersensitivity & Radiation )
 Pneumonia
 C/P
 Fever, cough and shortness of breath are the most common presenting
symptoms.
 These are usually preceded by a URTI.
 Other symptoms include lethargy, poor feeding, and appearing ‘unwell’.
Some children do not have a cough at presentation.
 Localized chest, abdominal, or neck pain is a feature of pleural irritation.
 Pneumonia
 EXAMINATION:
 Respiratory distress: Tachypnea, retraction, grunting, cyanosis
 Chest Examination:
 Air entry, crepitation, wheezes
 inspection: RD (Tachypnic & distressed ICR ,SCR, SSR, Acting Alanis )
 Palpation: TVF, position of the trachea
 Percussion: Dullness with consolidation, collapse or effusion
 Auscultation: decrease Air entry, crepitations,wheezes
 The most sensitive clinical sign of pneumonia s raised respiratory rate
 Pneumonia
 Investigations
 CBC, ESR, CRP
 Sputum Culter
 Blood culture: positive in 10% of patients with pneumococcal pneumonia
 Nasopharyngeal aspirate: for viral agents (RSV)
 PIeural fluid examination
 CXR
- Bacterial: Lobar consolidation (air bronchogram)
- Staph: Pneumatocele, abscess
- Viral: Parahilar shadows with radiating streaks
- Mycoplasma: Patchy segmental consolidation & hilar lynphadenopathy
 Pneumonia
 A chest X-ray is only necessary if there is doubt about the diagnosis .

 Neither a chest X-ray nor blood tests, including full blood count and
acute-phase reactants, are able to reliably differentiate between a viral
and bacterial cause.
Pneumonia
Pneumonia
 Pneumonia
 TREATMENT :
 Evidence-based guidelines for the management of pneumonia in childhood have been
published (BritishThoracic Society). Most affected children can be managed at home .
 indications for admission include
 oxygen saturation <92%, - Recurrent apnoea,
 grunting and/or an inability to maintain adequate fluid/feed intake.
 General supportive care for children requiring admission should include
 oxygen for hypoxia .
 analgesia for pain.
 Intravenous fluids should be given if necessary to correct dehydration and maintain adequate
hydration and sodium balance.
 Physiotherapy has no proven role.
 The choice of antibiotic is determined by the child’s age and the severity of illness
 Pneumonia
 Newborns require broadspectrum intravenous antibiotics.

 Most older infants can be managed with oral broaderspectrum antibiotics such as
Amoxil and co-amoxiclav reserved for complicated or unresponsive pneumonia.

 For children over 5 years of age, either amoxicillin or an oral macrolide suchas
clarithromycin is the treatment of choice.

 There is no advantage in giving intravenous rather than oral treatment

mild/moderate pneumonia unless the child is vomiting.
 Pneumonia
 Complications
 1 . Respiratory failure: Most serious
 2. Pleural effusion: Bacteria specially Staphyiococci & Streptococcus pneumoniae
 3. Lung abscess: Bacteria specially Staphylococci
 4. Pneumothorax: Bacteria specially Staphyloccoci & Klebsiella
 5. Myocarditis & Acute HF: In infants with severe bacterial infection
 6. Hematologic spread: Meningitis, arthritis, osteomyelitis...
 7. Complications of mycoplasma
 Pneumonia
 Complications of mycoplasma
 Bacterial superinfection :
 CNS: (Meningoencephalitis-Aseptic meningitis-GBS & transverse myelitis-
Ataxia)
 Hematological:(-Thrombocytopenia )
 Skin:(-Erythema multiform-Stevens-Johnson syndrome)
 Others:(-Hepatitis-Pancreatitis-Arthritis-Myocarditis & pericarditis)
 Pneumonia
 Prognosis and follow-up
 Follow-up is not required for a child with a simple pneumonia who makes a full clinical
recovery.

 Those with a lobar collapse or persistent symptoms should have a repeat chest X-ray
after 4–6 weeks to confirm resolution.

 Virtually all children with pneumonia, even those with empyema, make a full recovery
in high-income countries.
 Whooping cough (pertussis)
 This highly contagious respiratory infection is caused by Bordetella pertussis, which
produces pertussis toxin.

 A related organism, Bordatella parapertussis, causes a similar illness but it does not
produce pertussis toxin nd the illness is usually milder and shorter.

 Pertussis is endemic, with epidemics every few years

 Whooping cough (pertussis)
 C/P
1- Paroxysmal phase:
 paroxysmal or spasmodic cough followed by characteristic inspiratory whoop (paroxysmal phase).
 The spasms of cough are often worse at night and may culminate in vomiting (tussive vomiting).
 During a paroxysm, the child goes red or blue in the face, and mucus flows from the nose and mouth.
 The whoop may be absent in infants, but apnea is common at this age.
 Epistaxis and subconjunctival hemorrhage can occur due to vigorous coughing.
 The paroxysmal phase lasts up to 3 months.

2- convalescent phase
 The symptoms gradually decrease , but may persist for many months.

3- catarrhal phase
 Whooping cough (pertussis)
 Complications
1. pneumonia,
2. seizures
3. bronchiectasis are uncommon

 Investigation :Diagnosis is usually clinical

 per nasal swab cutler(The organism can be identified early in the disease
 PCR (polymerase chain reaction) is more sensitive.
 It can also be diagnosed serologically.
 marked lymphocytosis (>15 × 109/L) on a blood count.
 Whooping cough (pertussis)
 TREATMENT :
 macrolide antibiotics eradicate the organism, they decrease symptoms only if started
during the catarrhal phase.
 Siblings, parents and school contacts are at risk and close contacts should receive
macrolide prophylaxis.
 Unimmunized infant contacts should be vaccinated.
 Immunization reduces the risk of developing pertussis and the severity of disease if
affected but does not guarantee protection