PEDIATRICS 2

PEDIATRIC PULMONOLOGY / DR. J. TEVES / AUGUST 8, 2017

 Weight loss
 Contact with tuberculosis
 Chronic ear or nose symptoms (is there a problem with the cilia
function?)
 Relieving factors, such as bronchodilators or antibiotics
 Exposure to cigarette smoke
 Possible allergies and triggers
 Family history of atopy (is this ashma?) Or chronic respiratory
disorders
 Relation to feeding and swallowing (is there a problem with
aspiration?)
 Foreign body aspiration

RED FLAG FEATURES THAT SHOULD PROMPT SPECIALIST REFERRAL

 Neonatal onset of the cough
 Chronic moist, wet or productive cough
 Cough started and persisted after choking episode
PHYSICAL EXAMINATION  Neurodevelopmental problems also present
INSPECTION  Chest wall deformity
 Respiratory pattern, rate  Recurrent pneumonia
o < 2 mos = 60/min  Growth faltering
o 2- 12 mos = 50/min  Finger clubbing
o 12 mos- 5 yr = 40/min  General growth and development – immunodeficiency or co
o > 5 years = 30/min morbidities such as cardiac disease

BLOOD GAS ANALYSIS DIFFERENTIAL DIAGNOSIS

1. Upper Airway Cough Syndrome
• Single most useful test of pulmonary function
2. Asthma
• Direct measurement of art PO2, PCO2, pH 3. Mechanical Airway Obstruction
o pH = 7.35 - 7.45
4. GER/Aspiration Syndromes
o pCO2 = 35 – 45 5. Foreign Body Aspiration
o HCO3 = 18 – 26 6. Habit Cough
o a02 = 80-100 mmHg
Brochial Asthma 44 41.5%
DEFINITION
Pulmonary Tuberculosis 35 33.2%
 Cough
Atypical Pneumonia 17 16.4%
o Complex physiological reflex that consist of violent
expiration to release secretions, foreign matter to overcome Sinusitis 6 5.7%
bronchospasm or relieved diseases of the airways Otitis Media 2 1.4%
o Protect respiratory system AURI 1 0.9%
Di ko mabasa sa ppt 1 0.9%
EVALUATION OF A CHILD WITH COUGH
 Acute Cough ALGORITHM FOR EVALUATING CHRONIC COUGH IN CHILDREN
o 2 weeks duration
o URTI are common cause YES
Signs and symptoms of respiratory disease
o Resolves spontaneously EVALUATE FOR
NO
 Subacute Cough SPECIFIC COUGH
YES
o Between acute and chronic cough CXR, Spirometry abnormal
o 4 weeks duration
o Prolonged URTI or bacterial infection NO
 Chronic Cough Is cough characteristic?
o More than 4 weeks duration
o Causes vary depending on age NO
 Preschoolers NON SPECIFIC COUGH Review in 1-2wks
 Prolonged or overlapping URTI
 Asthma
 GERD Resolving, resolved Persistent Cough
 School children
1. Watch, wait, review
 Asthma 25% - usually post-infectious
 Postnasal drip 2. Evaluate Trial of therapy Watch, wait,
 GERD - tobacco smoke review
- Environmental exposures
IMPORTANT POINTS IN THE HISTORY OF A CHILD WITH CHRONIC - child’s activity
- parent concerns, expectations Dry cough: Wet cough:
COUGH 3. Di ko mabasa illness ICS 4-8wks Antibiotic 10-21days
 Nature of the cough
o Severity
o Time course
o Diurnal variability
o Sputum production
o Associated wheeze
o Disappears during sleep
o Any hemoptysis
 Immunixation status (DTP)
 Fever

Trans Group: ROGADO | VALERO | ANTE | EXCONDE | MENESES | YAYEN

Edited By:
Page 1 of 8
PEDIATRICS II: PEDIATRIC PULMONOLOGY

SPECIFIC COUGH
DIAGNOSIS
 clinical, X-ray of the neck subglottic narrowing “Steeple sign”
YES Reversible airway
ASTHMA obstruction? TREATMENT
 airway management, tx of hypoxia
NO  cold steam- no evidence supporting use of cold mist
Assess risk factors for:  nebulized racemic epinephrine-fluid resorption and dec laryngeal mucosal
edema
Bronchiectasis recurrent pneumonia
Aspiration  steroids- oral dexamethasone 0.6 mk single dose -dec edema in the
Chronic or less common infections laryngeal mucosa
Protracted bacterial bronchitis o IM dexamethasone and inhaled budesonide same effect
Airway abnormality  antibiotics, sedatives, expectorants and antihistamine – not indicated
Other less common pulmonary conditions
Cardiac disease RADIOGRAPH

Or consider referral to allergy pulmonary

or gastroenterology specialist

DISEASES OF THE UPPER RESPIRATORY TRACT

OBSTRUCTIVE SLEEP APNEA
 Repeated episodes of airflow obstruction at the nose and mouth that
occurs during sleep
 caused by adenotonsillar hyperplasia
 Triad
o snoring- most common
o nocturnal breathing difficulties
o respiratory pauses during sleep
ACUTE EPIGLOTTITIS
Nocturnal symptoms  Now rare but potentially lethal
 loud disruptive snoring, breathing pauses, gasping arousal  Seen in 1st yr up to 7 yr of age
 restless sleep and nocturnal diaphoresis  H influenza type b was the most common etiology but reduced due to
vaccine other causes strep pyogenes, s pneumonia staph aureus
Daytime symptoms  Abrupt onset of high fever, sore throat, dyspnea
 morning headaches from CO2 retention, chronic mouth  Rapidly progressing respiratory obstruction and death
 breathing, nasal speech and nasal congestion  drooling of saliva, hyperextended neck, dysphagia are common
 secondary enuresis, poor appetite, failure to thrive  Usually, no other family member are ill with ARI
DIAGNOSIS
PHYSICAL EXAMINATION  Laryngoscopy
 dysmorphic “adenoid” fascies o large, “cherry-red”,
 mouth breathing o swollen epiglottis
 hyponasal speech o other supraglottic structures
 macroglossia  Radiograph
 enlarge tonsils o thumb sign
 obesity or failure to thrive

DIAGNOSIS
 Polysomnography
o gold standard
o assess gas exchange impairment CO2 and O2 saturation,
thoracoabdominal movement, resp pattern
 lateral neck-evaluates size of adenoids

TREATMENT
 adenotonsillectomy (T and A)
 continous or bilevel positive airway pressure
 (nasal CPAP or BiPAP)
TREATMENT
COMPLICATIONS
• Airway management- endo or naso tracheal intubation for 2-3 days
 pulmonary hypertension, right sided hearth failure and cor pulmonale
• Ceftriaxone, cefotaxime,or meropenem for 10 days
 Failure to diagnose and treat: serious but generally reversible
• Racemic epinephrine and steroids- ineffective
consequences
• Chemoprophylaxis when exposed child develops febrile illness
 Attentional capacity, memory, and cognitive function, and increased
• Rifampicin 20mg/kg OD for 4 days: max dose 600mg
behavior problems
o all household members
o child <4 y.o incomplete immunized
DISEASES OF THE LOWER RESPIRATORY TRACT o younger than 12 mos not completed primary vaccine series
CROUP: LARYNGOTRACHEOBRONCHITIS (LTB) o immunocompromised
 most common, caused by parainfluenza viruses in 75%
 affects children 3 mos to 5 yrs peak at 2yr
 mild URTI, low grade fever for 1-3 days
 barking cough hoarseness with inspiratory stridor
 other family members have mild respiratory illness with laryngitis

Find the things that take your breath away

Page 2 of 8
PEDIATRICS II: PEDIATRIC PULMONOLOGY

ACUTE SPASMODIC LARYNGITIS  Bacterial Pneumonia

o brief URTI illness followed by abrupt onset of shaking chills,
• Familial predisposition high fever, cough and chest pain, restlessness, rapid
• Clinically similar to LTB except absent of viral prodrome fever in the respirations circumoral cyanosis may be observed
patient and family are absent o PE findings:
• Etiology: viral, allergic, psychological, represent more allergic reaction  diminished breath sounds, crackles and dullness
to viral antigen seen in consolidation or effusion
• Occurs frequently at night as coryza and hoarseness, barking or
metallic cough, noisy inspiration, and resp distress DIAGNOSIS
• Usually no fever
• Severity of the symptoms diminishes within several hours  Chest radiograph -confirms diagnosis, indicate complication
o Viral pneumonia – hyperinflation with bilateral interstitial
DIAGNOSIS infiltrates
 X-ray subglottic narrowing o Pneumococcal pneumonia – lobar consolidation
TREATMENT (same as LTB)  White Blood Cell
 airway management, tx of hypoxia o viral pneumonia normal not >20,000 lymphocyte
 cold steam- no evidence supporting use of cold mist predominance
o Bacterial pneumonia ranges 15,000 – 40,000 granulocyte
 nebulized racemic epinephrine-fluid resorption and dec laryngeal
predominance
mucosal edema
 Definitive diagnosis:
 steroids- oral dexamethasone 0.6 mk single dose -dec edema in the
o Viral – isolation of virus in respiratory tract secretions
laryngeal mucosa
o Bacteria – isolation of organism from blood pleural fluid
o IM dexamethasone and inhaled budesonide same effect
o Mycoplasma – cold agglutinins titer>1:64 in blood, PCR test
 antibiotics, sedatives, expectorants and antihistamine – not indicated
TREATMENT
ACUTE BRONCHITIS
 OPD:
• Transient inflammation of trachea and bronchi
o Amoxcillin – mildly ill, do not require hospitalization or
• Consequence of viral infection, secondary bacterial infection with
cefuroxime, amoxicillin/clavulanate
strep pneumo or H.influnzae
o Macrolides – erythro, clarithro, azithromycin atypical
• Dry hacking non-productive cough pneumonia
• Becomes congested cough and sputum change from clear to purulent  Hospitalized:
• PE: rhonchi, crackles o Bacteria – parenteral cefuroxime,
• Resembles the wheezing of asthma o Staphylococcal – cloxacillin, vanco, clinda
 Table on criteria for admission for pneumonia *see appendix*
DIAGNOSIS:
• clinical; laboratory not helpful
CONDITIONS PRESENTING WITH WHEEZE
• X-ray - nonspecific.
BRONCHIOLITIS
TREATMENT:
 Inflammatory obstruction of small airways
• no specific therapy, self limited
 Occurs during the first 2 years of life; peak at 6 mos.
• B2 agonist if wheezing is present
 Caused by RSV in >50%
• cough suppressants for symptomatic relief but increase the risk of
suppuration and inspissated secretions  Bronchiolar obstruction due to
o edema
• Antibiotics do not hasten improvement
o accumulation of mucus & cellular debris
• Antihistamines dry the secretions not helpful
o invasion of the smaller bronchial radicle by virus
SYMPTOMS:
PNEUMONIA
 start as mild URTI with sneezing and clear rhinorrhea and fever
 Inflammation of the Parenchymal of the Lungs  gradually of resp. distress paroxysmal wheezy cough, dyspnea,
 Streptococcus pneumonia (pneumococcus) most common bacterial irritability
pathogen
 PE:
 Other pathogens: o wheezing prominent findings, fine crackles
o Chlamydia pneumonia and mycoplasma pneumonia o tachypnea does not correlate with degree of hypoxemia
 Major causes of hospitalization and death or hypercarbia
o Streptococcus pneumoniae, haemophilus influenzae and DIAGNOSIS
staph aureus  clinical, previously healthy infant with first time wheezing
 Viral pathogens prominent cause of LRTI in infants and children  X-RAY- hyperinflation with patchy atelectasis
 Viral pneumonia – results from direct injury of respiratory epithelium,  BLOOD TEST-wbc and diff count normal
causing airway obstruction, abnormal secretions and cellular debris TREATMENT: Supportive
 M. Pneumonia – inhibits ciliary action and cellular destruction and  Cool humidified O2
inflammation sloughed cellular, debris, mucus and airway obstruction
 Bronchodilator- response is unpredictable, produce short
 S. Pneumonia – produce local edema result in focal lobar term improvement of wheezing
involvement
 Nebulized epinephrine- more effective than B2 agonist
 Group A Streptococcus results in more diffuse infection, necrosis of  Antibiotics –no value unless there is secondary bacterial
tracheobronchial mucosa, exudate, edema and local hemorrhage pneumonia
 Staph aureus -onfluent often unilateral, extensive hemorrhagic  Corticosteroids- often use despite conflicting studies but not
necrosis, cavitation, pneumatocoels empyema or bronchopulmonary
recommended in previously healthy infants
fistula
 Oral steroids-atopic wheezing, asthma
CLINICAL MANIFESTATION
ASTHMA
 Viral Pneumonia
o Symptoms of URTI, rhinitis and cough fever generally lower
 Characterized by chronic airway inflammation., associated with
o Tachypnea is the most consistent manifestation increased
airway hyperesponsiveness that leads to symptoms of asthma
work of breathing with retractions crackles and wheezing.
o Often not possible to distinguish viral from mycoplasma and
of the bacterial pathogens

Find the things that take your breath away

Page 3 of 8
PEDIATRICS II: PEDIATRIC PULMONOLOGY

 Defined by the history of respiratory symptoms i.e. wheeze, shortness Initial Assessment of Acute Asthma Exacerbation in ≤ 5 years
of breath, chest tightness and cough that vary over time and in
intensity SYMPTOMS MILD SEVERE
 With widespread, variable and reversible expiratory airflow limitation Altered consciousness No Agitated confused or
drowsy
 Variations are often triggered by factors: exercise, allergen or irritant
exposure, change in weather or viral respiratory infections Oximetry on >95% <92%
presentation **
Speech + Sentences Words
Pulse rate <100 beats / minute >200 bpm (0-3 years
old) >180bpm (4-5 yo)
Central cyanosis Absent Likely to be present
Wheeze intesity Variable Chest may be quiet
 *Any of theses indicates a severe exacerbation.
 ** Oximetry pre )2 or BD + normal development abnormality must be
considered

Classify Asthma Based on Severity (GINA 2002 – 2008)

INTERMITTEN PERSISTENT
SEVERITY T
Mild Moderate Severe
DIAGNOSIS Daytime < 1 x a weel ≥1x/week Daily, affects Daily, limits
Symptoms daily daily
 Recurrent episodes of wheezing, difficult breathing or chest tightness, activities activities
usually >1 symptom Night time ≤2x/month ≥2x/month Less than 1x Frequent
 Troublesome cough at night or early am symptoms per week
 Cough or wheeze after exercise
 Cough, wheeze or chest tightness in a seasonal pattern or after PEF ≥80% predicted ≥80% >60 - <79% >60%
exposure to airborne allergens or pollutants predicted predicted predicted
 Colds “go to the chest” or take more than 10 days to clear PER ≤20% 20-0% >30% >30%
 Symptoms respond to anti-asthma therapy Variability variability variability variability variability
 Personal/family history of asthma, atopy or allergic rhinitis FEV1 ≥80% ≥80% 60-79% <60%
 History and patterns of symptoms
 Measurements of lung function
o Spirometry
o Peak expiratory flow
 Measurement of airway responsiveness
 Measurements of allergic status to identify risk factors
 Extra measures may be required to diagnose asthma in children 5
years and younger and the elderly
 THERAPEUTIC TRIAL

5 days SABA + steroids

Indications:
1. Children 5 years and younger
2. Pulmonary function tests like spirometry and PEFR
measurement are note feasible / available.
PEAK EXPIRATORY FLOW RATE
 Expected PEFR = Height in cm – 100 X 5 + 174 (males) or 170
(females)
 Actual PEFR / Expected PEFR X 10

Find the things that take your breath away

Page 4 of 8
PEDIATRICS II: PEDIATRIC PULMONOLOGY

 Extrinsic compression from lymph nodes that encircle its bronchus

and drain both the middle and upper lobe

BRONCHIECTASIS
 Irreversible abnormal dilatation of the bronchial tree.
 Pathogenesis – three basic mechanism
1. Obstruction – because of foreign body, impacted mucuos poor
mucocillary clearance, external compression.
2. Infection – measles, TB, pertussis induce chronic inflammation,
bronchial wall damage and dilatation.
3. Chronic inflammation similar to obstruction leads to
bronchiectasis
 Most Common Cause:
o Difficulty clearing secretions and recurrent infections
TYPES
 Cylindrical
o Diffuse dilatation of bronchial unit affect muscles and
connected tissue
 Saccular
o Affects the cartilage of the airway causing ballooning of
bronchi
o Most severe form of bronchiectasis
SYMPTOMS AND PHYSICAL FINDINGS
 Cough and copious purulent sputum production-most common
complaint.
 Hemptysis
 Crackles, wheezing, digital clubbing
DIAGNOSIS
 CXR – non specific, cystic spaces with air fluid level
 HRCT – gold standard, provides disease location mediastinal lesion
and extent of involvement
TREATMENT
COUGH VARIANT ASTHMA  Medical – dec airway obstruction and control infection chest
physiotherapy, bronchodilators
 Frequently under diagnosed if no Hx of recurrent wheezing.  antibiotics two -4 weeks parenteral
 Cough may be the main symptom.  Surgical – localized lesion more severe resistant to med treatment.
 Dyspnea usually absent or minimal DISEASE OF THE PLEURA
 PE: mostly normal  Inflammatory process of the pleura
 Chest xray : normal o Dry or plastic
o Serofibrinous pleurisy
 PFTs may be diagnostic proof with increased in FEV1 after SABA of
o Empyema
>20%. Dry or Plastic Pleurisy
 Trial on ICS on LTRA w/ salbutamol.  Most commonly associated with infection of the lung
 Small amount of yellow serous fluid and adhesion
ATELECTASIS  Pain exaggerated by deep breathing coughing and straining.
 Rough friction rub, dullness and suppressed breath sounds.
 Incomplete expansion or complete collapse of the air-breathing Serofibrinous Pleurisy
tissue.  Associated with acute bacterial pulmonary infection
 Results from obstruction of air intake into the alveolar sac  Pleuritic pain is absent as fluid accumulates
 Associated with the absorption of air contained in the alveoli, which  Cough, dyspnea, retractions during large fluid collections.
are no longer ventilated.  Chest x-ray shows homogenous density
CLINICAL SYMPTOMS AND FINDINGS Purulent Pleurisy (Empyema)
 Small area – asymptomatic  Pus in the pleural space
 Associated with pneumococci and H. Influenzae or staph aureus.
 Large area – dyspnea, rapid shallow breathing, cough and often
 Most patients are febrile
cyanosis.  Older children have greater respiratory difficulty
 Chest appears flat on affected side.
 Limitation of chest excursion decreased breath sound and coarse
crackles dullness to percussion.
DIAGNOSIS
 Chest Xray- Opacity, wedge-shaped density.
TREATMENT:
 Antibiotics
 Bronchodilator / corticosteroid – in asthma
 Bronchoscopy
 Postural drainage
RIGHT MIDDLE LOBE SYNDROME
 Absent or aeration and bronchial obstruction
 Associated with PTB and Asthma

Find the things that take your breath away

Page 5 of 8
PEDIATRICS II: PEDIATRIC PULMONOLOGY

PLEURAL EFFUSION

Types

 Exudates - either from inflammatory diseases of pleural space.

 Transudates - Hydrostatic and oncotic pressure forces favor liquid
production rather than absorption.

TB effusion less toxic

Pleural fluid exudates, serous
protein >5g/dl
>50 lymphocytes
Treatment anti TB drug (4 drugs) PNEUMOTHORAX

 Accumulation of air within the chest

CT scan
 leakage of air within the diseased lung,
• to assess complications, extensions of pneumonia, lung abscess
• to rule out other diseases, effusion caused by tumors  Trauma, external chest
 Symptoms: abrupt onset of respiratory distress
 PE: markedly decreased breath sounds percussion note is
tympanitic
 Spontaneous
o Primary - someone without trauma or underlying lung
disease occurs in teenagers, male, tall, thin presence of
family history of spontaneous pneumothorax
o Secondary -Complication of an underlying lung disorder
but without trauma like pneumonia, pulmonary abscess
Diagnosis:
 X-ray: hyperluscent (black) without lung markings
 Needling of the ant. chest- bubbling
Treatment:
 Small <15% pneumothorax
 N2 washed-out method
Thoracentesis
>15% collapse,recurrent or under tension- Chest tube
thoracostomy

Antibiotics
• empirical treatment
GASTROESOPHAGEAL REFLUX
• S. pneumoniae – most common
• Increased incidence of CPE from 1996 –1999 then declined with use
 reduced lower esophageal sphincter tone
of pneumococcal vaccine
Closed thoracostomy drainage indications  cough occurs when there’s an acid reflux in the distal esophagus
- gross pus  stimulate the vagus nerve
- + organism on gram stain Symptoms: cough occurs while awake and upright
- pH < 7.0 - regurgitation of food , dysphagia.
- glucose < 40mg/dl Pathophysiology
- LDH > 1000 IU Microaspiration and vagal reflexes elicited in the esophagus may
- volume ? result in respiratory symptoms like cough and wheezes
- respiratory distress? PE: failure to thrive, wheezing
Dx:
 Barium esophagogram,
 24 hr pH-gold standard
Treatment: Supportive

Find the things that take your breath away

Page 6 of 8
PEDIATRICS II: PEDIATRIC PULMONOLOGY

 Medical- Domperidone,PPI
 Surgery - Fundoplication

POST NASAL DRIP

 accumulation of aspirated secretions at night.
 cough worst in the morning .
 nasal discharge, sinus symptoms.
 seasonal component suggest allergy.
PE:
 mucopurulent secretions in the oropharynx.
 cobblestone appearance in Post-pharynx

Physical examination
o Dark discolouration of
the periorbital skin
(allergic shiners).
o Horizontal wrinkle near
the tip of the nose
(allergic crease).
o Pale and swollen inferior
turbinates with clear
nasal discharge.
o Total serum Ig E 300 (<
100 kiu/ml), with
eosinophilia on nasal
smear.
o Positive skin prick test
for dog, cat dander,
House dust mites mix,
feather mix.

UPPER AIRWAY COUGH SYNDROME (UACS)

Clinical diagnosis
o “PND, nasal discharge, throat-clearing” caused by rhinosinusitis
o Historical reports of post nasal or pharyngeal syndromes –unreliable

• Cough receptors in the larynx stimulated by PND vs upper airway reflex

(vs united airways)
• One of the most common causes of chronic cough in children, singly or in
combination

CHRONIC SINUSITIS

• If patient responds to oral antibiotics, but becomes symptomatic

shortly after discontinuing antibiotics, consider 3-4 week dose
• Routine sinus x-rays don’t correlate well
• CT scan
• Nasal steroids may be helpful
• Nasal saline/ solution (NSS) irrigation is beneficial

HOW CAN PSYCHOGENIC COUGH BE RECOGNIZED?

• Habit or “Tic”like cough
• Purposeless dry barking repetitive cough after an URTI has cleared
• Disruptive, bizarre and honking with no organic cause
• More prominent in the presence of teachers of caregivers
• Absent at night during sleep
Treatment
No response to medication
Family therapy
Manifestation of underlying stress or family conflict

TAKE HOME MESSAGE:

• Know the classifications and identify the pointers
• Post infectious cough should be considered initially
• Bronchial asthma is the most common cause of chronic cough locally
• Chest x-ray and spirometry (if available) are initial lab of choice
• Treat the cause!
• Antitussive may be considered but NOT a first line of treatment
• Other cough medicines (mucolytic, expectorants) is usually not
helpful.

Find the things that take your breath away

Page 7 of 8
PEDIATRICS II: PEDIATRIC PULMONOLOGY

APPENDIX

Find the things that take your breath away

Page 8 of 8