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Respiratory Disorders in
Children
Chronic Respiratory Conditions
ü Bronchial Asthma
ü Emphysema
ü Chronic Bronchitis
ü Bronchiectasis
qPulmonary Tuberculosis
— Acute Pharyngitis
– “tonsillitis, tonsillopharyngitis”
– Group A b-hemolytic streptococcus
– 4 – 7 yrs. Old
– Headache, abdominal pain, vomiting, petechial
mottling of soft palate (strep)
– Throat swab for strep antigen, throat culture
– Otitis media- most common complication
– Penicillin – drug of choice for strep
Acute Respiratory Conditions
ü Common Cold
ü Pneumonia
ü Influenza
ü Acute Respiratory Distress Syndrome
ü Acute Respiratory Failure
ü Pneumothorax
qAcute Upper Respiratory Infections
qBronchitis and Bronchiolitis
qForeign Body Aspiration
Upper Respiratory Tract Infections
— Acute Nasopharyngitis
– “URI”, common colds
– Average of 3- 8 URI/year
– Rhinovirus
– First 2 yrs. of life
– Fever, irritability, sneezing
– Differential dx: foreign body obstruction, allergic
rhinitis
– Otitis media-most common complication
— Retropharyngeal Abscess
– Complication of Bacterial pharyngitis
– Retropharyngeal space - potential space bet
posterior pharyngeal wall & prevertebral
fascia
– Most frequent in children < 3 yr of age
– Grp A hemolytic strep, oral anaerobes, staph
aureus
– Fever, difficulty of swallowing, drooling
– Bulging of posterior pharyngeal wall
– Complication: aspiration of pus
– Meds: semisynthetic penicillin. Clindamycin,
ampicillin-sulbactam
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Retropharyngeal Abscess — Sinusitis

◦ Maxillary & ethmoid – anatomically present in
utero
◦ Frontal – develop by age of 1-2 yr
◦ Frontal & Sphenoid –radiologically present only at
5-6 yrs of age
◦ Strep pneumonea, moraxella catarrhalis, H.
influenzae
◦ Cough, nasal discharge – most common symptoms
◦ Fever, peri orbital edema, facial pain
◦ (+) air fluid level & opacification
◦ Complications: meningitis, subdural abscess

— Epiglottis Thumb sign

– “supraglottitis”

– H. influenza b
– 2 – 7 yrs old
– Severe airway obstruction death
– Inspiratory stridor
– “tripod sign”
– Cherry red epiglottis
– Keep airway patent
– Meds: cephalosporin
Epiglottitis

— Croup Chest X-Ray

– “Laryngotracheobronchitis” or LTB
– Fever, brassy cough, inspiratory stridor
– Occurs in young children
– Mx: steam inhalation, dexamethasone,
racemic epinephrine
– Contraindicated: opiates or sedatives

Acute Laryngotracheobronchitis

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Steeple sign
— Laryngitis
– Acute Spasmodic Laryngitis
– Similar to LTB w/ absent of history of URI
– Afebrile, barking cough

– Acute Infective Laryngitis

– Caused by viruses
– Subglottic area – principal site of
obstruction
– Loss of voice
Viral Laryngotracheobronchitis

Bacterial Tracheitis
— Bacterial Tracheitis
– Life threathening airway obstruction
– S. aureus
– < 3 yrs old
– Follows an apparent viral infection,
measles
– As complication of intubation
– Direcr laryngoscopy – pus
– Mx: intubation/ tracheostomy, antibiotics

Bacterial Tracheitis

Pseudomembrane
Diptheria • Gray, thick,
• Unvaccinated children fibrinous
• Acute
• Bleeds on
• Tonsils, pharynx, larynx, nose, skin,
attempted
mucous membranes
removal
• Mild- catarrhal form
• Severe- Grayish white pseudomembrane
surrounded by erythema

Diphtheria Diphtheria

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Clinical presentation Bullneck

• Incubation 1-6 days
• Classic respiratory diphteria- insidious onset
• URTI 3-4 days
• Fever, membranous pharyngitis, sore throat,
CLAD
• Bull-neck appearance

Diphtheria

Clinical presentation Management

• Laryngeal diphtheria • Diphtheria antitoxin
• Increasing hoarseness, stridor • IV penicillin then oral x 14 days
• Toxic • Mechanical ventilation
• Upper airway obstruction- dislodgment of • Tracheostomy
the pseudomembrane • IV dexamethasone
• Others: toxin-mediated myocarditis, • Immunization during convalescence
neuritis, secondary pneumonia • Prophylaxis – Penicillin, Erythromycin
• Death
Diphtheria Diphtheria

Lower Respiratory Tract Infections — Bronchiolitis

– Respiratory syncytial virus – 50%
— Acute bronchitis – Occurs during the 1st 2 yrs of life (peak – 6 month of
– Gradual onset age)
– Preceeded by URTI – “ball valve” type of obstruction hypoxemia
– Fever, conjunctiva injection, rhinitis, dry hacking, V/Q mismatch respiratory failure
non-productive cough – Critical phase – first 48 – 72 hrs
– Chest pain, wheezing, rhonchi – Fever. Cough, wheezing, dyspnea
– CXR – increase AP diameter w/ hyperinflation
– MX: oxygen, ribavirin (virazole)

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2y/o child presenting with chronic cough, bronchiectasis on

Acquired xray, with digital clubbing

— Foreign Bodies
◦ Location: nose, trachea, bronchus
◦ Sudden onset
◦ Croupy, barking cough
◦ Hoarseness, aphonia (larynx)
◦ Recurrent lobar pneumonia, intractable
asthma

Ballpen tip found in the left lower bronchus of a child with persistent
respiratory symptoms & abnormal xray (persistent atelectasis, left
lung) Patient subsequently underwent removal of the foreign body Tuberculosis in Children
via rigid bronchoscopy by the ENT.

— Etiology: mycobacterium tuberculosis

— Droplet’s inhalation lungs
— Incubation peroid: 2 - 10 weeks

National Children’s Hospital 2004

Tuberculin Test
— Mantoux test — Positive PPD
— PPD- RT23 (2-TU PPD-RT23)
— > 10 mm induration
◦ WHO & IUATLD
– Children < 5 yr old
— 5-TU PPD-S
◦ ATS & CDC – BCG immunized children
— > 5 mm induration
0.1 ml of the 2TU of RT23 will have a – Children > 5 yr old
tuberculin reactivity similar to 0.1 ml of the 5 – Non-BCG vaccinated children
TU of PPS-S

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TB Infection vs. Disease

— Accelerated BCG reaction on “BCG test” — TB infection
◦ Induration (at least 5 mm) – 48 – 72 hrs ◦ (+) tuberculin skin test
◦ Pustules - 5 – 7 days ◦ No sign & symptoms
◦ Healing – 2 – 3 weeks ◦ (-) CXR
— TB disease
◦ (+) tuberculin skin test
◦ (+) signs & symptoms
◦ (+) CXR

TB Classification
— Class I (TB Exposure) — Class II (TB infection)
◦ (+) exposure to anadult/adolescent w/ ◦ (+/-) history of exposure
activeTB ◦ (+) mantoux tuberculin test
◦ (-) signs & symptoms of TB ◦ (-) signs & symptoms of TB
◦ (-) mantoux tuberculin test ◦ (-) chest radiograph
◦ (-) chest x-ray

— Class III (TB disease)

◦ A child who has active TB has 3 or more of the following
criteria:
1. (+) hx of exposure to an adult/adolescent w active TB disease
— Class IV (TB inactive)
2. (+) mantoux tuberculin test ◦ A child/adolescent with or without history of
3. (+) signs & symptoms: one or more of the ff should be present:
n Cough/wheezing > weeks; fever > 2 weeks previous TB and any of the following:
n Painless cervical &/or other lymphadenopathy
n Poor weight gain; failure to make a quick return to normal after an – (+/-) previous chemotherapy
infection (measles, tonsillitis, whooping cough); failure to respod to
appropriate antibiotic therapy(pneumonia, otitis media) – (+) radio logic evidence of healed/calcified TB
4. Abnormal chest x-ray suggestive of TB
5. Laboratory findings suggestive of TB – (+) mantoux tuberculin test
– (-) signs & symptoms
– (-) smear/culture for M.tuberculosis

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Management of Newborns of
Chest X-Ray
Tuberculous Mothers

— Case 1
◦ Mother – TB infection
– (+) PPD , No evidence of disease

◦ Baby –
give BCG at birth

Miliary TB The Intensive Course in Pediatric

Pulmonology

— Case 2
◦ Mother – TB disease
– Treatment for 2 weeks or more
◦ Baby –
Start isoniazid at birth
Do mantoux test at 4 – 6 weeks
PPD (-) à continue INH
Repeat PPD after 3 months
PPD (-) à D/C INH, give BCG
PPD (+) à CXR (-) à
CXR (+) à
— Case 3
◦ Mother – TB disease, untreated
– Do not separate the newborn
◦ Baby –
At birth – start Isoniazid & rifampicin
- do PPD , CXR PPD (-) CXR (-)
Repeat PPD after 3 month:
PPD (-) CXR (-) mother completed TX BCG
PPD (+) CXR (-) continue INH & RIF for 6 more
month
PPD (+) CXR (+) continue INH, RIF for 6 more months
INH 6 more months + PZA for 2 months
INH, RIF 6 month
PZA 2 month

Chest X-Ray Chest X-Ray

Normal The Intensive Course in Pediatric

Pulmonology Pneumonia The Intensive Course in Pediatric
Pulmonology

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Chest X-Ray Chest X-Ray

Consolidation The Intensive Course in Pediatric

Pulmonology Staphylococcal Pneumonia
The Intensive Course in Pediatric
Pulmonology