STUDENTS-RESPIRATORY_CHILD
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Transcript STUDENTS-RESPIRATORY_CHILD
Respiratory
Disease In
Childhood
Nick Connolly
Paediatric SpR
NHS Tayside
Respiratory problems in
children
Neonatal respiratory problems
Respiratory problems in older children
Chronic
Acute
Scenario
An infant born at 30 weeks
gestation develops respiratory
distress at age 2 hours
Respiratory Distress Syndrome
Relative Surfactant deficiency
1% all births
Predominantly in preterm – inverse relationship
with gestation
Surfactant
Phospholipid
Apoproteins
Secreted at 30-32/40
Lack of surfactant results in atelectasis and
impairment of gas exchange
Production stimulated by steroids
Incidence of RDS relative to gestational age
100
90
80
70
60
50
40
30
20
10
0
% with clinical RDS
26
28
30 32 34 36
Gestational Age
38
40
Further problems
Ventilated
Sudden deterioration requiring increased oxygen
No breath sounds on the right side of chest
Pneumothorax
Air in pleural space
Increased incidence with IPPV, CPAP and
ventilation
Other risk factors – RDS (stiff lungs)
Spontaneous - occurs in around 1% vaginal
deliveries, 1.5% caesarean sections
Chronic Lung Disease
Oxygen requirement beyond 36 weeks corrected gestation
plus evidence of pulmonary parenchymal disease on CXR
Generally follows RDS
Barotrauma, volume trauma, high inspired oxygen
Healing stage associated with continued lung growth over
2-3 years – often wheezy
Scenario
New born full-term infant with
severe breathing difficulty after
birth
?Dextrocardia
Diaphragmatic Hernia
Incidence:1/2400
Associated pulmonary hypoplasia
Commonest- Posterolateral (Bochdalek), left-sided
Avoid bag-mask IPPV?
Respiratory support
Surgical
Older Children
Examination
Weight(length/height)..plotted!
?clubbing
Chest shape
Auscultation
Breathing tests
Chronic problems
Cystic fibrosis
A 1 year-old child presenting with a prolonged
history of cough, loose stools and failure to thrive
A newborn infant with a raised immuno-reactive
trypsin level on neonatal screening who is also
found to be homozygous for the ΔF508 deletion
Cystic Fibrosis
Autosomal recessive
Carrier incidence roughly 1 in 25 people
Mutations in the CFTR gene
Multisystem disorder
Respiratory infections are prominent
Differential diagnosis
Immune deficiency
Ciliary dyskinesia
Asthma
Kartagener’s/ immotile cilia syndrome- rare
Scenario
NM is a 7 month old infant with
cystic fibrosis who was admitted
with 2 chest infections.
He grew Staphylococcus aureus
on his respiratory secretions
Cystic Fibrosis Team
Clinician
Specialist nurse
Clinical psychologist
Social worker
Physiotherapist
Dietician
A 7-year child presents to your
clinic with a 3-month history of
cough worse at night or during
active play
Diagnosis: ASTHMA
Asthma – Diagnosis in Children
SIGN Guideline May 2008
Clinical Features that increase probability:
One or more : wheeze, cough, chest tightness,
difficulty breathing
Atopy(personal or family history)
Widespread wheeze on auscultation
Response to Rx
Asthma – Diagnosis in Children
SIGN Guideline May 2008
High Probability – diagnosis of asthma likely
(trial of Rx – further Ix if poor response)
Low Probability – consider Ix & ? Referral
Intermediate Probability: ?watchful waiting
?spirometry(response)
? Rx & evaluate
Asthma – Diagnosis in Children
Management
Stage 1: Treat with inhaled beta-agonists when
needed
Stage 2: Treat with regular inhaled steroids
Stage 3A: Regular inhaled steroids + Long acting
beta agonists
Stage 3B: Stage 3A + Leukotriene antagonists
Passive Smoking
Reduces birthweight by 250g
4500 pregnancy losses p.a.
30% increase in Perinatal Mortality
Teratogenic : airways, cleft lip/palate
Glue ear
Carcinogenic
4 million children live with smoking parent
Increase likelihood of asthma attack
Acute problems
Acute asthma
Cough and wheeze worsening
over hours or days
Treatment
Oxygen
Nebulised bronchodilator
Oral prednisolone
IV salbutamol
IV aminophylline
IV magnesium
Ventilatory support
Scenario
6 week old presented with increased work of
breathing and possible apnoes
URTI symptoms over last 2 days
Bronchiolitis
Viral infection – RSV
Usually under 18 months old
More severe in younger babies, ex prem, family of
smokers
Tachypnoea, poor feeding, irritating cough
Apnoea in small babies
Treatment is supportive
Increased incidence of wheezing episodes in the next
?10 years
Scenario
10 year old girl with cough, high
fever and sputum production
Previously very well
Clinical examination:
Dullness on percussion
Vocal fremitus and resonance
Bronchial breathing
Pneumonia
Neonates: GBS, E.coli, Klebsiella, Staph aureus
Infants: Strep pneumoniae, Chlamydia
School age: Strep pneumoniae, Staph aureus, Gr A
strep, Bordetella, Mycoplasma, Legionella
Scenario
A 2-year old child presenting with
barking cough and difficulty in
breathing of sudden onset
Differential Diagnosis
Inhaled foreign body
Laryngomalacia
Epiglottitis and bacterial tracheitis
Allergy
Croup
Croup
Viral laryngotracheobronchitis
Stridor, barking cough
Treatment is oral steroid to reduce inflammation
Scenario
9 month old infant from
developing country with
irritability, neck rigidity, afebrile
Pulmonary Tuberculosis
Mycobacterium tuberculosis
Notifiable disease
1/3 of World Population!
Droplet infection
Prevention(of severity): BCG
Drug treatment:
2 mths- Isoniazid, Rifampicin,
Pyrazinamide
4 mths- Isoniazid, Rifampicin
Common respiratory problems
in children
Infant respiratory distress syndrome
CLD
Congenital diaphragmatic hernia
Cystic fibrosis
Asthma
Bronchiolitis
Childhood pneumonias
Croup
Tuberculosis
FINISHED