PEDIATRIC

PULMONOLOGY
‫ هيفاء الضياني‬.‫د‬
Clinical features of respiratory tract
disorders
 Cough.
 Respiratory noises – wheeze, stridor, crackles.
 Increased rate of breathing.
 Increased work of breathing – dynamic chest
recession.
 Reduced oxygen saturation which improves with
supplemental oxygen and respiratory support if
necessary.
Dawn classification of RD
UPPER RESPIRATORY TRACT
INFECTIONS
Upper respiratory tract infections (URTI)

 Children have an average of five URTIs per year in the

first few years of life, but some infants and primary
school-age children have as many as 10–12 per year.
 Approximately 80% of all respiratory infections are
URTIs.
 Cough may be troublesome and may be secondary to
attempts to clear upper airway secretions or a
postnasal drip.
 Hospital admission may be required if feeding and
fluid intake is inadequate.
Upper respiratory tract infections (URTI)

 These infections affect upper

respiratory tract include:
Common cold.

 Otitis media.
 Pharyngitis (sore throat).
 Sinusitis (sinus infection).
 The child may have a combination of these

conditions.
Upper respiratory tract infections (URTI)

 The commonest presentation is a child with

a combination of nasal discharge and
blockage, fever, painful throat and earache.
 Cough may be troublesome.

 URTIs may cause:

 Difficulty in feeding in infants

 Febrile convulsions
 Acute exacerbations of asthma.
 Common cold (coryza)
 This is the commonest infection of childhood.
 Classical features include a clear or mucopurulent nasal
discharge and nasal blockage.
 The commonest pathogens are viruses – rhinoviruses,
coronaviruses and RSV.
 No specific curative treatment.
 Fever and pain are best treated with paracetamol or
ibuprofen.
 Antibiotics are of no benefit as the common cold is viral in
origin and secondary bacterial infection is very
uncommon.
 Cough may persist for up to 4 weeks after a common cold.
 Sore throat (pharyngitis)
 The pharynx and soft palate are inflamed and
local lymph nodes are enlarged and tender.
 Sore throats are usually due to viral infection

with respiratory viruses (mostly adenoviruses,

enteroviruses and rhinoviruses).
 In the older child, group A β-haemolytic

streptococcus is a common pathogen.

 It is not possible to distinguish clinically

between viral and bacterial pharyngitis.

 Tonsillitis
 It is a form of pharyngitis where there is intense
inflammation of the tonsils, often with a purulent
exudate.
 Common pathogens are group A β-haemolytic
streptococci and the Epstein–Barr virus (infectious
mononucleosis).
 Marked constitutional disturbance, such as
headache, high grade fever, apathy,vomiting and
abdominal pain, white tonsillar exudate and
cervical lymphadenopathy, is more common with
bacterial infection.
 Tonsillitis
 Antibiotics (often penicillin, or erythromycin if there
is penicillin allergy) are often prescribed for 10 days.
 In severe cases, children may require hospital
admission for intravenous fluid administration and
analgesia if they are unable to swallow solids or
liquids.
 Amoxicillin is best avoided as it may cause a
widespread maculopapular rash if the tonsillitis is
due to infectious mononucleosis.
 Early complications as peritonsillar abscess and late
autoimmune complications as rheumatic fever or
Acute otitis media (OM)
 Most children will have at least one episode of acute
otitis media (OM).
 Acute inflammation of the middle ear is a common
complication of acute nasopharyngitis especially in
late infancy and early childhood (6 months to 5years).
 Infants and young children are prone to acute otitis
media because their Eustachian tubes are short,
horizontal and function poorly.
 The illness is mostly bacterial and can be caused
mainly by streptococcus pneumonia or Hemophilus
influenza.
Acute otitis media (OM)
 There is pain in the ear and fever usually after
attack of nasopharyngitis.
 Every child with a fever must have their tympanic
membranes examined.
 Ear examination with otoscope reveals a
congested bulging eardrum.
 Occasionally, there is acute perforation of the
eardrum with pus visible in the external canal.
Acute otitis media (OM)
 Serious complications include: mastoiditis,
meningitis, brain abscess and Acute cerebral
thrombophlebitis.
 Acute otitis media can be complicated with

chronic suppurative or secretory otitis

media (hearing loss).
Acute otitis media (OM)
 Pain should be treated with an analgesic such as
paracetamol or ibuprofen.
 Most cases of acute otitis media resolve
spontaneously.
 Antibiotics marginally shorten the duration of
pain but have no shown to reduce the risk of
hearing loss.
 An oral broad-spectrum antibiotic (as
ampicillin,50 mg/kg/day) to cover both gram-
positive and gram-negative organisms is
prescribed for 7-10 days.
Laryngotracheobronchitis(
Croup)
 Laryngotracheobronchitis(Croup)
 There is mucosal inflammation & oedema of the subglottic
area that is potentially dangerous in young children
because it may result in critical narrowing of the trachea.
 Viral croup accounts for over 95% of laryngotracheal

infections. Parainfluenza viruses are the commonest

cause.
 Croup occurs from 6 months to 6 years of age but the

peak incidence is in the second year of life.

 It is commonest in the autumn but sporadic cases occur

throughout the year.

 Clinical features
 The typical features are a barking cough, harsh stridor
and hoarseness, usually preceded by fever and coryza.
 The symptoms often start, and are worse, at night.
 Stridor can be classified to : mild, moderate or severe
 When the upper airway obstruction is mild, the stridor
and chest recession disappear when the child is at rest.
 The child can usually be managed at home. The parents
need to observe the child closely for the signs of
increasing severity.
 Clinical grading of stridor
 Grade 1(exertional stridor):
 Only during crying or exercises
 Grade 2:
 Continues even at rest & more with exercise.
 Grade 3 :
 Stridor with suprasternal and to less extent
intercostal retraction
 Grade 4:
 Stridor with cyanosis
Diagnosis
 Diagnosis is often made solely on clinical
grounds
 X-ray neck (PA view)—Subglottic narrowing or

“steeple sign” seen as tapering column in

upper trachea.
 Steeple sign may be absent in patients and

Xray findings do not indicate severity of

airway obstruction.
 Laboratory tests are of limited value
 Management
Mild (no stridor at rest): Treat with minimal disturbance,
cool mist, hydration, antipyretics, and consider steroids.
Moderate to severe:
 Child should be encouraged to stay in a position

comfortable to them with good hydration

 Humidified oxygen for hypoxic patients

 Racemic epinephrine 0.25–0.5 mL of 2.25% racemic

epinephrine in 3 mL of normal saline

 Dexamethasone, 0.3 to 0.6 mg/kg IV, IM, or PO once.

 A helium-oxygen mixture may decrease resistance to

turbulent gas flow through a narrowed airway.

 Management
 After administering of racemic epinephrine
observe for a minimum of 2 to 4 hours, owing to
potential for rebound obstruction
 Hospitalize if more than one nebulization required.

 If a child fails to respond as expected to therapy,

o consider other etiologies (e.g., retropharyngeal abscess,

bacterial tracheitis, subglottic stenosis, epiglottitis,
foreign body).
o Obtain airway radiography, CT, and evaluation by
otolaryngology or anesthesiology.
o Consider intubation and mechanical ventilation.
Differential diagnosis of Stridor
 Common causes
 Viral laryngotracheobronchitis (‘croup’)
 Foreign body
 Rare causes
 Laryngeal oedema (anaphylaxis and recurrent croup)
 Laryngomalacia
 Inhalation of smoke and hot fumes in fires
 Trauma to the throat
 Retropharyngeal abscess
 Bacterial tracheitis or epiglottitis
 Diphtheria
 Severe lymph node swelling (malignancy, tuberculosis, infectious
mononucleosis, measles)
 Hypocalcemia
Acute epiglottitis
Acute epiglottitis
 Acute epiglottitis is a life-threatening
emergency due to the high risk of
respiratory obstruction.
 It is caused by H. influenzae type b.

 There is intense swelling of the epiglottis

and surrounding tissues associated with

septicaemia.
 Epiglottitis is most common in children

aged 2–6 years but affects all age groups

 Clinical features
The onset of epiglottitis is often very acute with:
 High fever in an ill, toxic-looking child

 An intensely painful throat that prevents the child

from speaking or swallowing

 Saliva drools down the chin

 Soft inspiratory stridor and rapidly increasing

respiratory difficulty over hours

 The child sitting immobile(tripod position), upright,

with an open mouth to optimize the airway.

Diagnosis
 Diagnosis requires direct visual confirmation of inflamed
epiglottis.
 Direct laryngoscopy shows large, cherry red, swollen
epiglottis .
 There is variable involvement of supraglottic structures as well.
 Direct Laryngoscopy can be risky procedure in these patients
and should be performed in a controlled environment, ideally in
an operating theatre or intensive care unit where facility for
emergency intubation is in place.
 Lateral X- ray of neck reveals the swollen epiglottis, the
characteristic “thumb sign”.
 Cultures of blood, epiglottic surface should be collected after
airway is stabilized
 Treatment
 If the diagnosis of epiglottitis is suspected, urgent hospital
admission and treatment are required.
 The child should be intubated under controlled conditions.
 Rarely, this is impossible and urgent tracheostomy is life-
saving.
 Intravenous antibiotics such as Ceftriaxone or Cefotaxime or
Meropenem and modified according to result of culture &
sensitivity.
 Antibiotics given for 7-10 days.
 With appropriate treatment, most children recover
completely within 2–3 days.
 Prophylaxis with rifampicin is offered to close household
Bacterial tracheitis
Bacterial tracheitis
 Bacterial tracheitis is a rare but serious
superinfection of the trachea that may follow viral
croup and is most commonly caused by S. aureus.
 Patients may be toxic appearing with a very ill-
looking, a high fever.
 In contrast to croup, their stridor is soft.
 Children with bacterial tracheitis also have
copious, thick airway secretions.
 They have rapidly progressive airways obstruction.
Bacterial tracheitis
 If the diagnosis of bacterial tracheitis is suspected,
urgent hospital admission and treatment are
required.
 Calm administration of oxygen with nebulized
adrenaline will usually offer some temporary
benefit.
 Treatment must be initiated without delay.
 Only after the airway is secured should blood be
taken for culture and intravenous antibiotics
started.
Whooping cough (Pertussis)
Whooping cough (Pertussis)
 This is a highly contagious respiratory infection
caused by Bordetella pertussis..
 A related organism, Bordatella parapertussis,
causes a similar illness but it does not produce
pertussis toxin and the illness is usually milder and
shorter.
 Pertussis is endemic, with epidemics every few
years.
 Incubation period of 7–10 days.
 The child is infectious for up to 3 weeks after the
onset of bouts of whooping cough.
 Clinical features
 After an incubation period, the child has fever,
usually with a cough and nasal discharge that are
clinically indistinguishable from the common cough
and cold (catarrhal phase).
 In the second week, there is paroxysmal or

spasmodic cough followed by a 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.
 Clinical features
 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 episodes of coughing usually take 2-4

weeks and can continue for 3 months or

longer.
 The symptoms then gradually decrease over

1-2 weeks (convalescent phase), but may

persist for many months.
Diagnosis
 Suspect pertussis if a child has had severe
cough for more than 2 weeks.
 The most useful diagnostic signs are:

 Paroxysmal coughing followed by a whoop when

breathing in or with vomiting
 Subconjunctival hemorrhage
 Child not vaccinated against pertussis
 Young infants may not whoop cough followed by
apnea or cyanosis, or apnea may occur without
coughing.
Diagnosis
 The organism can be identified early in the
disease from culture of a pernasal swab,
although PCR (polymerase chain reaction) is
more sensitive.
 It can also be diagnosed serologically.

 Characteristically, there is a marked

lymphocytosis (>15 × 109/L) on a blood

count.
 Treatment
 Treat mild cases in children aged ≥ 6 months at
home with supportive care.
 Admit infants aged < 6 months to hospital; also
admit any child with pneumonia, convulsions,
dehydration, severe malnutrition or prolonged
apnea or cyanosis after coughing.
 Antibiotics: Give oral macrolide (erythromycin for
10 days or azithromycin for 5 days ).
 This does not shorten the illness but reduces the
period of infectiousness.
Prophylaxis
 Siblings, parents and school contacts are at
risk and close contacts should receive
macrolide prophylaxis.
 Immunization reduces the risk of developing

pertussis and the severity of disease if

affected but does not guarantee protection.
 The level of protection declines steadily

during childhood