Respiratory Disorders in

Children

Celia Sy, M.D. FPPS,FPAPP

Pediatric Pulmonologist
Anatomy

URT

LRT
Dilated esophagus
 Stages of Lung Development

 1. Embryonic
 Approx 4th wks of gestation
 Develop of the 2 main stem bronchus
 Seperation of forgut fr coelomic cavity
 2. Pseudoglandular
 6th weeks of gestation
 Separation of trachea from forgut
 Formation of diaphragm
Chest X-Ray

Congenital Diaphragmatic Hernia

The Intensive Course in Pediatric Pulmonology
 3. Cannalicular
 16th and 26-28th weeks of gestation
 Presence of type I & II pneumatocytes
 Limited gas exchanges by 22 wks
 4. Saccular
 26th-28th wks of gestation
 Widen of terminal airways & saccule formation
 5. Alveolar
 29th wks – birth
Question 1
 Tracheoesophageal fistula is formed at what
stages of lung development?
 Pseudoglandular stage
 Diaphragmatic hernia is formed at what
stages of lung development?
 Pseudoglandular stage
 Gas exchange is first presence at what
stage of lung development?
 Canalicular stage
Static Lung Volume
 Tidal volume
 Volume of normal breathing
 Vital Capacity
 Maximal expired volume after maximal
inhalation
 Inspiratory reserve volume (IRV) + tidal
volume (TV) + Expiratory reserve volume
(ERV)
 Residual volume
 Volume remaining after maximal exhalation
 Functional residual capacity
 Expiratory reserve volume (ERV) + residual
volume (RV)
 Total lung capacity
 vital capacity (VC) + residual volume (RV)
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
 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
 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
 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
 “supraglottitis”
 H. influenza b
 2 – 7 yrs old
 Severe airway obstruction death
 Inspiratory stridor
 “tripod sign”
 Cherry red epiglottis
 Keep airway patent
 Meds: cephalosporin
 Croup
 “Laryngotracheobronchitis” or LTB
 Fever, brassy cough, inspiratory stridor
 Occurs in young children
 Mx: steam inhalation, dexamethasone,
racemic epinephrine
 Contraindicated: opiates or sedatives
Chest X-Ray

Acute Laryngotracheobronchitis
The Intensive Course in Pediatric Pulmonology
 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
 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
Lower Respiratory Tract Infections

 Acute bronchitis
 Gradual onset
 Preceeded by URTI
 Fever, conjunctiva injection, rhinitis, dry
hacking, non-productive cough
 Chest pain, wheezing, rhonchi
 Bronchiolitis
 Respiratory syncytial virus – 50%
 Occurs during the 1st 2 yrs of life (peak – 6 month of
age)
 “ball valve” type of obstruction hypoxemia
V/Q mismatch respiratory failure
 Critical phase – first 48 – 72 hrs
 Fever. Cough, wheezing, dyspnea
 CXR – increase AP diameter w/ hyperinflation
 MX: oxygen, ribavirin (virazole)
 Bronchiolitis Obliterans
 Progressive airways obstruction
 Inflammation & granulations tissue formation
of small airways
 Associated with adenovirus infection
 Common complications of lung transplant
 May be delayed by corticosteroids
 Pneumonia
 Causative agents: bacteria, virus,
mycoplasma, aspiration
 Severity: mild, moderate, severe
 WHO: No pneumonia, pneumonia, severe
pneumonia
 Location: lobular, lobar, bronchopneumonia
Chest X-Ray

Normal The Intensive Course in Pediatric Pulmonology

Chest X-Ray

Pneumonia The Intensive Course in Pediatric Pulmonology

 Bacterial Pneumonia
 Chidren > 2 months of age
 Most common microorganisms: S. pneumoniae
H. influenzae
 Most common symptoms: fever, cough, dyspnea

 Children < 2 months old

 Most common microorganisms: Group b strep
E. coli
 +/- fever
 Tachypnea - most reliable sign
 Pneumococcal pneumonia
 90% cases
 Lobar involvement
 CXR: lobar consolidation
 H. Influenzae pneumonia
 Insidious onset
 Predeed by URTI
 Nosocomial infection
 no characteristics clinical / radiological patterns
Chest X-Ray

Consolidation The Intensive Course in Pediatric Pulmonology

 Staphylococcal pneumonia
 Occurs in young infants
 Associated with septicemia, skin infections,
measles
 Serious, rapid progressive course of illness
 Extensive bilateral lung involvement
 CXR: nodular infiltrates, multiple abscesses,
empyema, pneumothorax
 Meds: penicillinase-resistant penicillin
Chest X-Ray

Staphylococcal Pneumonia
The Intensive Course in Pediatric Pulmonology
 Klebsiella pneumonia
 Thick-rusty sputum
 Bulging of fissures
 Pulmonary abscess & cavitations
 Pseudomonas pneumonia
 Immunocompromised, debilitating
patients
 Prolonged mechanical ventilatory support
 HIV
 CXR: presence of necrosis
Case 1
 3 y/o F, fever, cough & difficulty of breathing of 3 days duration. PPE:
febrile, alar flaring, stridor, drooling of the saliva. Patient was noted to
assume a “tripod” position
 Questions:
 Where is the site of the lesion?
 A. URT B. LRT
 What is the probable diagnosis in this case?
 A. pneumonia B. laryngitis C. epiglottitis
 What are the expected clinical findings?
 A. bulging of posterior pharyngeal wall
 B. cherry red epiglottis
 C. floppy epiglottis
 What is the antibiotic of choice?
 A. penicillin B. cephalosporin c. ampicillin
 Preventive measures is best achieved by:
 A. vaccination B. primary chemoprophylaxis C. post-exposure antibiotics
 Non-Infectious Disorders of
the Respiratory Tract
 Congenital  Acquired
 Nasal hypoplasia  Allergic rhinitis
 High arch palate  Epistaxis
 Choanal atresia  FB obstruction/
 Laryngomalacia aspiration
 Tracheomalacia  Nasal polyps
 Congenital Central  Nasal septal
Hypoventilation deviation /
Syndrome perforation
Congenital
 Choanal atresia
 Unilateral or bilateral bony(90%)or
membranous(10%) septum between the nose &
the pharynx
 Associated w/ CHARGE syndrome – coloboma,
heart disease, atresia choanae, retarded growth
& development or CNS anomalies or both;
genital anomalies or hypoganadism or both; &
ear anomalies or deafness, or both
 Dx: inability to pass a firm catheter through each
nostril 3 -4 cm into the nasopharnx
Congenital
 Laryngomalacia
 Most common congenital laryngeal abnormality
 Flabbiness of epiglottis & supraglottic apperture
 Floppy arytenoid cartilages
 Short aryepiglottic folds
 Noisy, crowing respiratory sounds during
inspiration – “Halak”
 Diagnosed by direct laryngoscopy
 Resolves spontaneously
laryngomalacia, patient.mpg
BURNS - omega epiglottis.mpg
Congenital Central Hypoventilation
Syndrome CCHS (Ondine’s curse)

 Primary CNS defect

 Term, AGA
 Resp failure, slow & irregular respiratory pauses,
cyanosis
 appear on the 1st day of life
 Px fail to respire adequately during sleep, not during
wakefullness
 No sensitivity to carbon dioxide & hypoxemia
 No ventilatory response to CO2 during sleep
 PCO2 to 80 -90 mmHg during sleep
Obstructive Sleep Apnea
(OSA)
 Upper airway obstruction 2nd to
adenotonsillar hypertrophy
 Triad: Snoring, noctural breathing
difficulty, respiratory pauses
 Polycythemia, respiratory acidosis &
metabolic alkalosis, RVH
 PSG (polysonograph)- diagnostic “gold
standard”
Acquired
 Epistaxis
 Kiesselbach’s plexus – most common
location for bleeding
 Stop spontaneously in most cases
 Local application of oxymetazoline or
neosynephrine (0.25 – 1 %)
Acquired
 Nasal polyps
 Benign pedunculated tumors formed from
edematous, chronically inflamed nasal mucosa
 Glistening, gray, grape like masses squeezed
bet the nasal turbinates & septum
 Cystic fibrosis – most common childhood cause
of nasal polyposis
 Mx: intranasal steroids, surgical removal
Acquired
 Foreign Bodies
 Location: nose, trachea, bronchus
 Sudden onset
 Croupy, barking cough
 Hoarseness, aphonia (larynx)
 Recurrent lobar pneumonia, intractable
asthma
Chest X-Ray

Foreign Body Aspiration The Intensive Course in Pediatric Pulmonology

2y/o child presenting with chronic cough,
bronchiectasis on xray, with digital clubbing
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 via rigid bronchoscopy by the
ENT.

National Children’s Hospital 2004

Plant fragments

Royal Children’s Hospital 2008

Aspiration Pneumonia
 Predisposing condition
 Congenital
 Esophageal atresia
 Cleft lip/palate
 Duodenal obstruction
 GER
 Acquired
 Debilitated infants
 Cerebral palsy
 Materials commonly aspirated:
 Milk, cereals, food
 Vomitus
 Baby powder
 Hydrocarbon (Kerosene)
 Lipoid materials
 Medicated oils
 Cod liver oils
Kerosene Aspiration
 Most common in the Philippines
 Low viscosity, High volatility
 cough, fever, dyspnea, hypoxemia,
cyanosis
 Pneumothorax, subcutaneous empysema,
pleural effusion
 All symptomatic should be admitted for
observation
 Gastric lavage is contraindicated
Chest X-Ray

Pneumothorax The Intensive Course in Pediatric Pulmonology

Chest X-Ray

Pleural Effusion The Intensive Course in Pediatric Pulmonology

Kerosene Aspiration
 No patient should be sent home in < 6
hrs.
 All symptomatic patient should be
admitted
 Gastric lavage is containdicated
Congenital Lung Anomalies
 Lung agenesis
 Bilateral – incompatible with life
 Lung hypoplasia
 Associated w/ persistent fetal
hypertension & ipsilateral diaphragmatic
hernia
 Pulmonary Sequestration
 Mass of non-functioning embryonic &
cystic pulmonary tissue that receives its
blood supply from the systemic artery
 2 Types:
 Intralobar
 Extralobar
 Angiogram – “gold standard” diagnostic
tool
Chest X-Rays

The Intensive Course in Pediatric Pulmonology

Aortogram

Pulmonary Sequestration
The Intensive Course in Pediatric Pulmonology
 Bronchogenic Cysts
 Abnormal budding of the tracheal
diverticulum of the forgut
 Lined w/ ciliated epithelium
 Located at the midline between the
trachea & esophagus or carina
 Cyst with air-fluid level
Chest X-Ray

Bronchogenic Cyst The Intensive Course in Pediatric Pulmonology

 Congenital Cystic Adenomatoid
Malformation (CCAM)
 Malformation of the terminal bronchiolar
structure
 Contains small amount of normal lung tissue w/
many glandular elements
 Single lobe of one lung is enlarged & often cystic
 Ipsilateral lung may be hypoplastic
 Left lower lobe – most common
 Congenital Lobar Emphysema
 Single or multiple lobe
 Left upper lobe – most common
Tuberculosis in Children
 Etiology: mycobacterium tuberculosis
 Droplet’s inhalation lungs
 Incubation peroid: 2 - 10 weeks
Tuberculin Test
 Mantoux test
 PPD- RT23 (2-TU PPD-RT23)
 WHO & IUATLD
 5-TU PPD-S
 ATS & CDC

0.1 ml of the 2TU of RT23 will have a

tuberculin reactivity similar to 0.1 ml of the 5
TU of PPS-S
 Positive PPD
 > 10 mm induration
 Children < 5 yr old
 BCG immunized children
 > 5 mm induration
 Children > 5 yr old
 Non-BCG vaccinated children
 Accelerated BCG reaction on “BCG
test”
 Induration (at least 5 mm) – 48 – 72 hrs
 Pustules - 5 – 7 days
 Healing – 2 – 3 weeks
TB Infection vs. Disease
 TB infection
 (+) tuberculin skin test
 No sign & symptoms
 (-) CXR
 TB disease
 (+) tuberculin skin test
 (+) signs & symptoms
 (+) CXR
TB Classification
 Class I (TB Exposure)
 (+) exposure to anadult/adolescent w/
activeTB
 (-) signs & symptoms of TB
 (-) mantoux tuberculin test
 (-) chest x-ray
 Class II (TB infection)
 (+/-) history of exposure
 (+) mantoux tuberculin test
 (-) signs & symptoms of TB
 (-) chest radiograph
 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
2. (+) mantoux tuberculin test
3. (+) signs & symptoms: one or more of the ff should be
present:
 Cough/wheezing > weeks; fever > 2 weeks
 Painless cervical &/or other lymphadenopathy
 Poor weight gain; failure to make a quick return to normal after
an infection (measles, tonsillitis, whooping cough); failure to
respod to appropriate antibiotic therapy(pneumonia, otitis
media)
4. Abnormal chest x-ray suggestive of TB
5. Laboratory findings suggestive of TB
 Class IV (TB inactive)
 A child/adolescent with or without history
of previous TB and any of the following:
 (+/-) previous chemotherapy
 (+) radio logic evidence of healed/calcified TB
 (+) mantoux tuberculin test
 (-) signs & symptoms
 (-) smear/culture for M.tuberculosis
Chest X-Ray

Miliary TB The Intensive Course in Pediatric Pulmonology

Mercado Endo TB.mpg
Management of Newborns of
Tuberculous Mothers
 Case 1
 Mother – TB infection
 (+) PPD , No evidence of disease

 Baby –
give BCG at birth
 Case 2
 Mother – TB disease
 Treatment for 2 weeks or more

 Baby –
Start isoniazid at birth
- do mantoux test at 4 – 6 weeks
PPD (-) continue INH

Repeat PPD after 3 months

PPD (-) D/C INH, give BCG

PPD (+) CXR (-) INH 6 more months

CXR (+) INH, RIF 6 month

PZA 2 month
 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
+ PZA for 2 months