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Dr AE Kappos Pulmonology RCWMCH 15 Feb 2012 Respiratory illness is very important
Major cause of death in childhood
Most common cause of acute and chronic illness
May also lead to permanent impairment of lung function and to chronic lung disease even into adulthood Cough
Most important DEFENCE mechanism of the body
Cough is our own personal physiotherapist
Most common presenting symptom of resp illness
INABILITY TO COUGH IS AN EMERGENCY
Cough suppression is CONTRAINDICATED IN CHILDREN UNDER 4 YRS (ESP <2 MONTHS) Cough continued
The linked image cannot be displayed. The file may have been moved, renamed, or deleted. Verify that the link points to the correct file and location. Persistent cough of >3 weeks with constitutional symptoms of weight loss and fever:RED FLAG for TB
“Barking cough,honking cough”:CROUP
“Whooping cough”:pertussis Tachypnoea
Fever
Anxiety
Pain
Dehydration (acidotic breathing/kussmaul breathing)
Lung Congestion (left to right cardiac shunts)
Pulmonary oedema
Severe anaemia, salicylate poisoning Respiratory rate limits
<2 months: 60 breaths/min
2-12 months: 50 breaths/min
1-5 years:40 breaths/min Signs of respiratory distress
Tachypnoea with Lower chest retractions
Nasal flaring( severe distress)
Resp failure : grunting, cyanosis , depressed level of consciousness Risk factors for severe acute resp infection
MEDICAL: <1 YR,Prem, Immunosuppresion
SOCIAL: overcrowding,passive smoking,inadequate housing,indoor fuel exposure
NUTRITIONAL: Malnutrition, lack of breastfeeding Oxygen delivery methods
Humidified low flow oxygen (0.5-3l/min) applied via NP02 is usually sufficient for hypoxic children( delivers 28-35% o2)
Headbox oxygen can be an alternative(does not require humidification but wastage and feeding can be problematic, FI02 delivery is unpredictable)
Facemask oxygen delivery 28-65% at flow rate 6-10l/min for children, not tolerated very well by infants
IN SEVERE HYPOXIA:use polymask (60-80% ) Noisy breathing
Implies obstruction
NB in diagnosis is pinpointing the site of obstruction and not labeling the noise as stridor/wheeze etc
The kind and loudness of noise is NOT helpful Noises according to site of obstruction
STRIDOR WHEEZE
Nasopharynx/throat + 0
Larynx + +
Trachea /bronchi + +
Peripheral airways 0 + Sites of obstruction
SITE COMMON CAUSES
Extrathoracic
1.Nose and nasopharynx Coryza, sdb
2.Larynx CROUP,Laryngomalacia
Intrathoracic
3.Trachea /bronchi Vascular ring,TB nodal compression,foreign body
4.Peripheral airways Asthma,bronchiolitis,BPN,CF,Aspiration syndromes,GOR,Chronic HIV lung disease Identifying the site of obstruction
Three questions:
Inspiration or expiration?
If in inspiration, is the obstruction present during mouth breathing?
If it is in expiration, is there air trapping present? Common resp conditions
LARYNGOMALACIA
Commonest cause of noisy breathing in neonates
Inspiratory noise starting from birth or usually from day 10 of life
Variability of obstruction with posture and breath
NO EXPIRATORY COMPONENT Laryngomalacia Laryngomalacia
Simple: larynx structurally normal Laxity of supraglottic tissues that are sucked into the lumen of larynx with inspiration
Resolves by 1 yr of age
Complex : Above symptoms with difficult drinking,dysphagia,laryngeal incompetence with pulmonary aspiration ,vocal cord paralysis
May ameliorate with growth but does not resolve totally Laryngomalacia
Investigations: Laryngoscopy Barium swallow if indicated
Management: REASSURANCE Mostly GOR treatment if present Laser excision of excess supraglottic tissue for severe obstruction Tracheostomy in some complex cases Bronchiolitis
Most common cause of severe acute viral LRTI in children< 2yrs
Usually caused by RSV /Rhinovirus
Highly infectious
Affects the peripheral airways causing BAT and often wheeze
Airway obstruction is due to inflammation and edema and not muscle constriction
Spreads via contaminated hands Bronchiolitis risk factors
HOST FACTORS: prematurity, congenital heart disease, CLD of prematurity, neurological disease, infants<6months, immune deficiency,lack of breastfeeding
ENVIROMENTAL: Poverty, overcrowding,passive smoke exposure, Day Care attendance Bronchiolitis Prevention
Avoid exposure to children and adults with colds
Frequent hand washing
Passive immunization with Palivizumab for premature infants and in infants with CLD and congenital heart disease (expensive and needs to be given monthly during RSV season)
RSV Season CT: rainy season and between autumn and winter Gauteng: Late Feb-August KZN : Feb -March (rainy season) Bronchiolitis Symptoms
History of 1-2 days of URTI symptoms of nasal congestion
with progressive tachypnoea
Seasonality Bronchiolitis signs
Bilateral wheezing (and crackles)
Bilateral air trapping with peripheral airways obstruction seen with Hoover sign and resonance with percussion over heart and upper border of liver
Tachypnoea
Downward displacement of liver and spleen because of hyperinflation (BAT) Bronchiolitis diagnosis
Clinical diagnosis based on history and clinical examination ONLY
No CXR warranted unless diagnosis doubtful and/or constitutional signs present
No indication for CRP
Oxygen sats in room air is important
Bronchodilator response test(most do not response but some do) Bronchiolitis indications for hospitalization
Oxygen sats <90% (inland), <92% (coast)
Severe respiratory distress/failure(grunting,cyanosis,nasal flaring)
Poor feeding
Apnoea
Prem infants with risk factors
Underlying medical condition(Congenital heart disease,CLD,Down syndrome)
Severe malnutrition Admission pre-requisites
Nurse alone in a cubicle (ie “in isolation”)
Or COHORT with children >2 yrs of age and no underlying risk factor for severe illness Bronchiolitis treatment
No medications indicated for children not requiring hospital admission
THE OBJECTIVE FOR HOSPITALIZATION IS TO MAINTAIN HYDRATION AND OXYGENATION thus
Feeding: if unable to feed ,feed via NG tube (small frequent feeds to avoid overdistention)
Humidified low-flow oxygen (0,5-3l/minute) VIA NASAL prongs (28-35%) is usually sufficient in hypoxic children Bronchiolitis treatment cont.
Antibiotics not indicated unless severe cases,requiring ICU admission, nosocomial acquisition of RSV or cyanotic congenital heart disease,immune deficiency to cover for bacterial co-infection
Bronchodilator therapy is not routinely recommended but if infants respond can be continued until symptoms improve
Hypertonic saline 3% nebs has shown benefit (ideal dosage not confirmed, can be given 2-6 hr) Bronchiolitis treatment NOT INDICATED
Do not give ADRENALINE
Do not give ICS or oral steroids
Do not do chest physiotherapy
Do not institute regular suctioning Bronchiolitis discharge and follow up
Discharge when drinking well and oxygen saturation is > 92% in room air
Some tachypnoea,air trapping and crackels may persist for up to 4 weeks
Review at outpatients 6-8 weeks after discharge by which time all airtrapping should have resolved.If still BAT consider:New infx,CF or GOR with micro-aspiration
Warn parents about post bronchiolitis wheezing CROUP
Pediatric equivalent of adult acute laryngitis
Clinical features:
Previously well, immunized against diptheria,initially runny nose, cough and difficult noisy breathing (inspiratory stridor) and chest retractions
Peak incidence at 2 yrs with occurrence from 4months to 4 yrs Features that are NOT CROUP
FEATURES CONDITION
Sudden onset, very severe obstruction Foreign body
<4 months Subglottic stenosis(congenital)
Incomplete immunization Diptheria
Severe oral thrush Candida laryngitis
Fever, erythema Staph tracheitis
Fever, sore Epiglottitis, retropharyngeal/peritonsilar throat,DROOLING,DYSPHAGIA ascess
Aphonia, previously hoarse Laryngeal papillomatosis CROUP diagnosis
Record oxygen saturations (sats<92% is uncommon and should warrant a re-evaluation of diagnosis)
Blood gases are unhelpful and unnecessary
X-ray confirmation only indicated if atypical features present:
Steeple sign of AP neck view is diagnostic of subglottic narrowing Normal AP view of neck “Steeple sign” Severity of CROUP
TREATMENT DEPENDS ON THE SEVERITY OF THE AIRWAY OBSTRUCTION and not on the noise (stridor)
THE GRADING IS THAT OF THE AIRWAY OBSTRUCTION and not the intensity of the stridor, as that gets softer as obstruction increases!!!!!!!!! Grading Criteria
Inspiratory obstruction: inspiratory noise (stridor), retractions, tracheal tug
Expiratory obstruction: visible or palpable contraction of rectus abdominal muscles during expiration
Pulsus paradoxus: pulse becomes weak or disappears with inspiration GRADES OF OBSTRUCTION
GRADE INSPIRATORY EXPIRATORY PULSUS OBSTRUCTION OBSTRUCTION PARADOXUS
I +
II + +
III + + +
IV Extremis,marked retractions,apathy,cy anosis Treatment
All grades of obstruction get CORTICOSTEROIDS (on diagnosis)
Prednisone 2mg/kg stat ORALLY
Dose can be repeated in 24 hours
(In severely ill children who are unable to swallow one can consider giving ivi Dex 0,6mg/kg stat- in extreme situations only)
If airway obstruction is worse 4 hours after steroids, diagnosis should be reviewed
Steroids are CONTRA-INDICATED in measles- in such instances intubate if warranted Treatment
Grade 1: can be sent home after stat dose pred with advice to return if worsening symptoms
Grade 2: Admit, monitor sats, check degree of obstruction 3 hourly
Give adrenalin nebs (in conjuction with steroids)half hourly
Comfort child
Avoid noxious stimuli
Continue normal feeds Treatment
Grade 3 and Grade 4
LIFE THREATENING
ADMIT TO ICU
CONTINUOUS ADRENALINE NEBS WITH OXYGEN
IF 6 HRS AFTER STEROIDS, STILL > GRADE 3 OBSTRUCTION, ENDOTRACHEAL INTUBATION IS INDICATED Discharge and follow up
Stop nebs when obstruction is grade 1
Can be discharged 6-8 hrs after last neb
Routine post croup follow up is not indicated
Can recur but seldom needs hospitalization\
Recurrences requiring hospitalization need to be referred Pneumonia: cough and a clinical sign
CLINICAL SIGN PNEUMONIA CATEGORY MANAGEMENT
Lower chest indrawing Severe pneumonia First dose ivi/im antibiotic, hospital referral
Tachypnoea Pneumonia Oral antibiotic
No tachypnoea/lower chest No pneumonia Supportive treatment indrawing GAAP Admission Criteria Oxygen via nasal cannula, face mask or head box if saturations are <92%
No difference between different modes of oxygen delivery as long as sats >92%
IVI fluids and electrolyte testing only in children that are vomiting or severely ill
Treatment AGE AMBULENT HOSPITALIZED
0-2 MONTHS RECOMMEND AMPICILLIN/PENICILLIN ADMISSION IVI + AMINOGLYCOSIDE (CEFTRIAXONE/CEFOTAX IME IVI)
>2 MONTHS-5 YRS HIGH DOSE ORAL IVI AMPI/HIGH DOSE AMOXYL (30MG/KG/DOSE AMOXYL TDS) (IVI CEFUROXIME.AUGMENTI N OR IVI CEFTRIAXONE/CEFOTAXI ME
> 5YRS Amoxycillin po high dose As above OR Macrolide if suspect Mycoplasma/Chlamydia Add aminoglycoside at any age if HIV infected or if severely malnourished
Add macrolide if Chlamydia suspected in <6 months
Add cloxacillin if fail to respond to treatment after 48 hours (especially > 2 months of age) or CXR changes suggesting empyema,pneumatocele or abscess
Add Macrolide in >5yrs if no response after 48 hrs on treatment and/or wheezing
Treat generally 5-7 days with antibiotics Treatment continued WHO recommendations in HIV infected children Pneumonia prevention
Immunization(esp Measles,pneumococcal)
Vitamin A
Zinc supplementation esp in malnourished pts
Nutrition(continued breastfeeding)
Avoiding passive smoke exposure
Preventing TB
Preventing ARI in HIV infected children (cotrimoxazole prophylaxis) Sleep Disordered Breathing
Upper airway obstruction during sleep
Mild to severe airway obstruction with intermittent totally obstructed episodes during sleep
The question to ask each parent is: “is the child SNORING?” at routine child care visits Adverse Effects of SDB
Fragmented sleep******* asphyxia Negative pleural pressure
Developmental delay: DEATH Aspiration pneumonia
Failure to thrive near-SIDS “Bronchitis”
Learning difficulties PERMANENT CNS Chest deformity DAMAGE
Behavioural problems Cardiac arrhythmia Pulmonary oedema
Pathological shyness Pulmonary hypertension
Morning headaches Congestive heart failure
Restless sleep Systemic hypertension (enuresis,sleep walking,nightmares)
DAYTIME sleepyness Diagnosis
History: snoring and/or disturbed sleep
Cell phone video of child sleeping
No special investigation is necessary to prove dx or assess severity
Rare cases where diagnosis is doubtful can admit for overnight/sleeping sats
SNORING IS COMMON thus isolated snoring for <3 months is usually benign
ABSENCE OF DAYTIME SYMPTOMS,NORMAL EXAM does not exclude SDB Diagnosis continued
Examination: usually normal, although severely affected children may have snoring sounds and mouth breathing even when awake.
LOOK for evidence of FTT, pulmonary hypertension
When asleep: noisy breathing and increased respiratory efforts
Special investigations:
X-ray of postnasal space for adenoidal tissue Post nasal space X-ray Diagnosis continued
FBC : polycythaemia (very rare)
ECG and cardiac echo insensitive guide to the severity of SDB(only a 1/3 of patients with severe obstruction have pulmonary hypertension) Treatment
Treat allergic rhinitis
Adenoidectomy: snoring >4 months despite medical treatment snoring with TOES/cyanosis complications adenoidal tissue on x- ray/endoscopy
Tracheostomy if associated with anatomical abnormality of nose /pharyngeal airway
CIP tube for life-threatening obstruction