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Fifth stage
Pediatric
كتابة الطالب
.د
فارس
4/10/2015
Respiratory diseases
General notes:
In pediatric Commonest causes of diseases or hospital admission or visiting doctor or
absent from school are respiratory and gastro-intestinal diseases then UTI.
Most of the causes of respiratory diseases in children are viral infection (80%-90%) so not
give antibiotics.
Commonest types of viruses are influenza, para-influenza, rubella, RSV, measles, …
Don’t prescribed any unnecessary drugs especially in pediatric lead to kidney and liver
diseases and toxicity and other risks.
Risk factors of respiratory disease:
Host factors age (younger more), sex (male more), CHD, atopy.
Environmental factors pollution, smoking, and mother care.
Strider:
It is harsh and high pitched sound (forceful breathing against closed glottis)
Due to obstruction
In the epiglottis
Common in winter and fall.
Causes: Croup, Acute epiglottitis, laryngeo-malasia, Foreign body inhalation.
Rare causes: vocal cord paralysis, laryngeal hemangioma.
Croup:
Viral infection.
Para-influenza virus 1,2,3.
Peak at 2 years.
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It last few days and rarely recurrent (only if positive family history).
Very rarely bacterial.
Begins with upper respiratory infection, rhinorrhea, respiratory distress, inspiratory strider,
barking cough (start at night), exhausted, edema of larynx, struggle to breathe, child only
want to sit.
Anything disturbed the baby or make him cry will increase the symptoms and can lead to
respiratory obstruction and death.
Diagnosis clinically (always examine baby in his mother's lap) and no need for
investigations.
X-ray STEEPLE sign. Subglottic narrowing of airways.
Treatment:
o At home Always try to calm the child, Good hydration, Steam inhalation, Anti-pyretic.
o At hospital
Indication of admission: moderate to severe symptoms, strider at risk, decreased level
of consciousness, cyanosis, need O2.
Give: humidified O2, single dose of Dexamethasone (6 mg/kg orally or parenteral),
Nebulized racemic epinephrine or L-epinephrine (for Broncho-dilatation), Monitor &
Observe.
Intubation (only in 1% of baby) or tracheostomy (But tracheostomy is easier because
there is edema in the airway)
Acute epiglottitis:
It is life threatening condition (Total airway obstruction).
Severe bacterial infection of epiglottis and subepiglottic fold.
Bacteria Hemophilus infleunzae type b, Strep.pyogens
Features sudden onset, high fever, toxic, sore throat, dysphagia, triode position,
drooling of saliva, dyspnea, collapse, coma, death (in few hours).
Clinical diagnosis (not use tongue depressor lead to respiratory obstruction)
Don’t take history, don't do x-ray.
Blood culture investigation is hazardous.
Do examination in theater room with available tools for intubation, tracheostomy and
anesthesia.
All children need intubation for 2-3 days.
Antibiotics for H.infleunzae (amoxicillin or ceftriaxone) for 7-10 days
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Then send child to home.
Give rifampicin to house hold members for 2 days to prevent meningitis due to
H.infleunzae.
Laryngo-malacia (floppy larynx) (infantile larynx):
Exaggerated collapse of larynx in inspiration.
Congenital.
Represent 60% of strider causes.
Usually present at birth , Less than 4-6 weeks of life start.
More than 6 weeks start more serious condition.
Simple, recover spontaneously after month or one year or two years.
Not need admission, not need treatment, not need investigations.
Strider at rest.
Become more in excretion like crying and feeding and disturbing the baby
No respiratory distress (important).
Flexible laryngeoscopy to confirm diagnosis.
Strider is more when there is upper respiratory infection.
Explain everything to parents.
Foreign body inhalation (aspiration)
Common in infants and toddlers. (Infant can swallow F.B because they explore
environment by their mouth).
Inhale small things like: فستق،سمش بح ،زرخ ،لباعد
History very important, healthy baby, sudden onset, parent deny something (social
circumstances).
Cause acute strider.
First stage severe paroxysm of cough, cyanosis, chock, sneezing, gagging.
Second stage Misleading (like a recovery state).
Third stage symptoms of complications because F.B go to the right lung and lead to
atelectasis, pneumonia, tachypnea, cyanosis, retractions, fever, and other symptoms.
Diagnosis clinically.
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Investigations CXR should be done in deep inhalation see localized hyperinflation,
most are radio-lucent.
Treatment upside down, big thrust on baby back, laryngoscope or bronchoscope,
tracheostomy (trans-thoracic approach).
Bronchiolitis:
Common wheezy infection.
Occur in few months up to 2 years.
Above 5 years rare.
Viral infection (RSV).
Rarely mycoplasma pneumoniae.
More in boys.
Breast feeding is protective.
Neonate (1 month) rarely have bronchiolitis and rarely have viral infection.
Wheeze is expiratory sound يوصوص
There is exposure to adult with upper RTI before one week.
Diagnosis clinically.
Features: rhinorrhea, cough, sneezing, common cold, low grade fever, respiratory distress,
cyanosis, tachypnea (120/min), wheezing, flaring ala nasi, recession, tired, hyperinflated
chest, air trapping, auscultation (wheezing, fine bilateral crackles), may feel liver and spleen
(due to hyperinflation), poor appetite, refuse eating.
Not diagnose H.F with radiological evidence of cardiomegaly.
CXR Flat diaphragm, narrow mediastinum.
No need for complete blood.
Viral diagnosis: immunoflurecnet of secretions, viral culture (slow process), serology
(antibodies).
Course of Bronchiolitis 1-stormy course 2-3 days // 2-plateau course 7-10 days. //
3-good condition after 10 days.
Treatment: mild care at home, monitor, semi-setting position (30 degree), good hydration.
Indication for hospital admission:
o Cannot eat give nasogastric tube.
o Less than 6 months age.
o Severe distress.
o Need O2.
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o Baby with high risk factors CHD, chronic lung diseases (broncho-pulmonnary
dysplasia), immune deficiency, neuromuscular weakness.
o Home condition is bad.
o Carless parents.
In hospital:
o Give humidified O2.
o Fluids (nasogastric)
o Monitoring.
o Head up.
o Nebulizer (salbutamol, adrenaline, hypertonic saline, helox <helium + O2> , inhaled
corticosteroids)
o No antibiotics only in superadded or secondary infection or fever or high patchy in
CXR for pneumonia.
o Antiviral agent.
Prevention: breast feeding, no vaccine for RSV, give annual vaccine for influenza,
monoclonal antibody (Palivizumab) for RSV given monthly in high risk and premature.
Pneumonia:
It is inflammation of lung parynchima.
Caused by infectious and non-infectious agents.
Age is very important:
o The commonest bacteria in pneumonia in all age groups are strepto pnemoniae,
H.influenzae.
o Neonate (less than 3 or 4 weeks) group B strepto, E.coli, G+ bacillus.
o Pneumonia in neonate is like septicemia give parenteral antibiotics for two weeks
then admission.
o After neonate viral infection.
o After 3 months chlamydia, uroplasma, mycoplasma.
o After age of 5 years most common is strepto pneumoniae then mycoplasma
pneumonia.
o Extra pulmonary features of mycoplasma are low grade fever, headache, cough.
o In immune-deficient patient penumocistis carini, pseudomonas areognosium, TB
bovis, fungus (histoplasam and candidia), and other rare micro-organisms.
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o Diagnosis of T.B CXR, Culture, skin test, gastric aspiration, not sputum test in
pediatric.
Clinical features dry cough, dyspnea, chest pain, graunting ()أنين, not depend on CXR
alone, crackles,
No bronchial breathing, high fever and chills in bacterial disease, tachypnea,
plural effusion in CXR in bacterial, wheezing, abnormal pain (GIT symptom of in lower lobe
pneumonia), Neck rigidity (CNS symptom of upper lobe pneumonia), diarrhea and vomiting
(occur in pneumonia).
30% of viral pneumonia has supper added bacterial pneumonia.
Diagnosis by CXR obacity, patchy infiltrate (viral), lobar infiltrate (viral).
Staph. pneumonia:
o High fever, toxic, dramatic and progressive course.
o CXR very characteristic lung abscess, empyema, plural effusion, pneumatocele.
o Come with septicemia and coma.
o Blood culture (+ve in 10% only)
o Give anti-staph drugs.
For mycoplasma pneumoniae azithromycin or clarithromycin.
For pneumococcus amoxicillin for 7-10 days (40-100 mg/kg in day)
Indication for hospital admission:
o Need O2.
o Less than 6 months age.
o Need fluid and supplements.
o Immuno-deficient baby.
o Slowly resolving pneumonia.
o Multiple infections.
Recurrent Pneumonia:
o More than 2 attack per year.
o Causes: sickle cell anemia, foreign body, TEF (H type), congenital anomalies, cystic
fibrosis, lung sequestration, opportunistic infections due to decrease immunity.
Prognosis:
o Clinical improvement takes 10 days.
o Radiological improvement takes 6 weeks.
o Don’t depend on radiological improvement, but depend on clinical improvement to stop
the regimen of management.
Slowly resolving pneumonia caused by F.B, bacterial resistance, congenital anomalies
(lung sequestration).