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COMMON PAEDIATRIC RESPIRATORY PRESENTATIONS (Aimed at Medical Students in Clinical Years and Foundation Doctors) Dr Sweatha Ananthalingam Foundation Year 1 Doctor – West Midlands Manchester Medicine – (2019 – 2024)WHY IS TH IS TOPIC IMPORTANT ? Respiratory disorders: • Cause more than 50000 deaths per year in children (1 month–5 years old ) worldwide • Cause 50% of consultations with GPs for acute illness in young children and 33% in older children – in the UK • Are collectively responsible for about 25% of acute paediatric admissions to hospital in the UK • Asthma is the most common chronic illness of childhood in the UK; 1 in 11 children in the UK receives treatment for asthma• https://www.youtube.com/watch?v=EYqi7hHBEVs&t=1s • https://www.youtube.com/watch?v=qsFR8evfrK8&t=3s • https://www.youtube.com/watch?v=KQTEu1mpRY8+Tachypnea, Tachycardia, Inability to feedSIGN S OF SEVERE RES PIRATORY D IST RESS • Cyanosis • Tiring due to increased work of breathing • Reduced conscious level • Oxygen saturation < 92% despite oxygen therapy • Rising partial pressure of Co2 Which children are more susceptible to respiratory failure?• Ex-preterm infants • Haemodynamically significant Congenital Heart Disease • Disorders causing muscle weakness • Cystic fibrosis (CF) or immunodeficiency.HOW D O CHILD REN WIT H RESPIRATORY DISORDERS PRES EN T? URT - coryza,sore throat, earache,sinusitis,Stridor LRT – cough,Wheeze and respiratory distress AIRWAY NOIS ES • Narrowing of the airway due to inflammation is a feature of many respiratory pathologies S TRIDOR • Due to upper airway narrowing that results in increased effort and added respiratory noise during inspiration • Extra thoracic airway obstruction – upper trachea and larynx • Harsh High pitched,whistling sound • Most common cause is laryngeal and tracheal infection,where mucosal inflammation and swelling can rapidly cause life-threatening obstruction of the airway in young children • One must avoid looking at the throat of a child with upper airways obstruction unless full resuscitation equipment and personnel are at hand. *Snoring is also inspiratory,but because it is caused by variable partial upper airway obstruction,it is a rough inspiratory noise DIFFERENTIAL DIAGNOS IS FOR ST RIDOR (UPP ER AIRWAY OBS TRUCT ION) Common causes • Viral laryngotracheobronchitis (‘croup’) Rare causes • Epiglottitis • Retropharyngeal abscess • Bacterial tracheitis • Hypocalcaemia • Laryngeal or oesophageal foreign body • Severe lymph node swelling (tuberculosis,malignancy) • Allergic laryngeal angioedema (seen in anaphylaxis) • Measles • Inhalation of smoke and hot fumes in fires • Diphtheria • Trauma to the throat • Psychological – vocal cord dysfunction CROUP • Typically affects children aged 6 months to 2 years • Commonest cause - parainfluenza virus. • Harsh, loud stridor • Coryza and Mild fever • Hoarse voice • Barking cough • Mainly supportive management • Oral dexamethasone is first line • In severe cases,nebulized epinephrine (adrenaline) with oxygen by face mask provides rapid but transient improvement.EPIGLOTTIT IS • Caused by Haemophilus Influenza B • Can cause complete airway obstruction within hours – EMERGENCY! • Rare due to vaccination programme – 99% reduction • Common in 1-6 years • Can present similar to Croup but Rapid Onset • Patient presents with sorethroat and stridor • Drooling,tripod position • High fever • Difficulty or painful swallowing • Typically no cough • Muffled voice • Scared and quiet child • Septic and very unwell appearance Remember the 4 D’s! – Dyspnoea,Dysphagia,Drooling,Dysphonia EPIGLOTTIT IS Investigations: Lateral Xray of neck Management: • Please don’t distress child – DO NOT examine throat • Main focus is securing airway • Escalate to senior paediatrician and anaesthetist(or ENT surgeon) • Oxygen,Nebulised adrenaline • Iv antibiotics(ceftriaxone) and Iv steroids • A common complication to be aware of is the development of an epiglottic abscess Croup Epiglottitis Time Course Days Hours Features Prior Coryza None Cough Barking Slight if any Feeding Can drink No Mouth Closed Drooling Saliva Toxic No Yes Fever <38.5 degrees >38.5 degrees Stridor Rasping Soft Voice Hoarse Weak or Silent URT - coryza,sore throat, earache,sinusitis,Stridor LRT – cough,Wheeze and respiratory distress UPP ER R ESP IRATORY TRAC T INFECTION S • 80% of all Respiratory infections involve only the Ear,Nose,Throat or sinuses. - Common cold (coryza) - Sore-throat(pharyngitis,tonsillitis) - Otitis Media - Sinusitis(relatively uncommon). • The most common presentation is a child with a combination of these conditions.OftenViral,self- limiting illness • Cough may be troublesome and in URTI may be secondary to postnasal dripWHEN DOES URTI BECOME CONC ERN ING? • Difficulty in feeding • Febrile Seizures • Acute exacerbations of asthma/Viral induced wheeze *Hospital admission is rarely required but may be necessary if feeding and fluid intake is inadequate* URT - coryza,sore throat, earache,sinusitis,Stridor LRT – cough,Wheeze and respiratory distressWHEEZE • Due to lower airway narrowing • Added respiratory noises during expiration • Increased intrathoracic pressure • Due to mucosal inflammation of lower trachea, bronchus and bronchioles DIFFERENTIALS – WHEEZE(LRT ) Common: • Bronchiolitis • Asthma (orViral Induced wheeze) Other Causes: • Foreign body inhalation - unilateral wheezing and air trapping • Atypical Pneumonia – pneumonia rarely causes wheezing,atypical pneumonia caused by Mycoplasma, Chlamydia or adenovirus can do so. • Anaphylaxis- suspect if acute urticaria,facial swelling BRONCHIOLIT IS • Common serious respiratory infection of infancy • 90% are aged 1–9 months. • Respiratory SyncytialVirus is the pathogen in 80% of cases. • Co-infection with more than one virus,particularly RSV and human metapneumovirus may lead to a more severe illness. • Coryzal symptoms precede a dry cough and increasing breathlessness. BRONCHIOLIT IS • Pulse oximetry should be performed on all children with suspected bronchiolitis. No other investigations are routinely recommended. • chest X-ray or blood gases are only indicated if respiratory failure is suspected. • Hospital admission is indicated if: ➢ Aged under 3 months or any pre-existing condition such as prematurity,Downs syndrome or cystic fibrosis ➢ apnoea (observed or reported) ➢ persistent oxygen saturation of < 92% when breathing air ➢ inadequate oral fluid intake (50–75% or less of usual volume) ➢ severe respiratory distress – grunting,marked ➢ chest recession,or a respiratory rate over 70 breaths/minute.MAN AGEMENT - BRONCHIOLIT IS • Supportive.Humidified oxygen is either delivered via nasal cannulae if needed • No evidence for reducing severity of illness has been shown from use of antibiotics,corticosteroids or bronchodilators. • Most infants recover from the acute infection within 2 weeks. Prevention of bronchiolitis: • A monoclonal antibody to RSV (palivizumab,given monthly by intramuscular injection) reduces the number of hospital admissions in high-risk preterm infants. VIRAL WHEEZE VS AST HMA •Presenting before 3 years of age •No atopic history •Only occurs during viral infections •Normal investigations(usually done after 5 years) *Expiratory wheeze throughout the chest- both asthma and viral wheeze If you hear a focal wheeze be very cautious and investigate further for a focal airway obstruction such as an inhaled foreign body or tumour.These patients will require an urgent senior review•Episodic symptoms with intermittent exacerbations •Diurnal variability,typically worse at night •Dry cough with wheeze and shortness of breath •A history of other atopic conditions •Family history of asthma or atopy •Bilateral widespread “polyphonic”wheeze heard by a healthcare professional •Symptoms improve with bronchodilatorsINVEST IGATIONS FOR ASTH MA • Spirometry with reversibility testing (in children aged over 5 years) • Direct bronchial challenge test with histamine or methacholine • Fractional exhaled nitricoxide (FeNO) • Peak flowvariability measured by keeping a diary of peak flow measurements several times a day for 2 to 4 weeks INH ALERS Pressurized metered dose Dry powder inhaler,4 years Nebulizer:all ages.Only used inhaler and spacer.Suitable and older. in acute asthma where for all ages, with face mask if oxygen is needed in addition under 2 years of age. to inhaled drugs. Q UEST ION 1 A 6-year-old boy is brought to the GP by his father due to a loud, harsh cough that has persisted for the past 2 weeks. The child has also been more lethargic than usual.Although he appears to be in good health, you observe 2 coughing fits during the consultation, which cause the child distress and difficulty breathing, resulting in a loud, harsh inspiratory noise between coughing fits. The patient has no known allergies or medical history, but his vaccination record is unclear since he moved to the UK from another country 3 years ago. The patient's temperature is 37.5ºC. What is the most appropriate course of action? A. Send to emergency department B. Prescribe azithromycin and report to Public Health England C. Reassure it is likely self-resolving viral illness and send home with safety netting D. Book the patient for an urgent Chest Xray E. Do nasal swabs with PCR testing or bacterial culture and prescribe oral dexamethasone Q UEST ION 1 A 6-year-old boy is brought to the GP by his father due to a loud, harsh cough that has persisted for the past 2 weeks. The child has also been more lethargic than usual.Although he appears to be in good health, you observe 2 coughing fits during the consultation, which cause the child distress and difficulty breathing, resulting in a loud, harsh inspiratory noise between coughing fits. The patient has no known allergies or medical history, but his vaccination record is unclear since he moved to the UK from another country 3 years ago. The patient's temperature is 37.5ºC. What is the most appropriate course of action? A. Send to emergency department B. Prescribe azithromycin and report to Public Health England C. Reassure it is likely self-resolving viral illness and send home with safety netting D. Book the patient for an urgent Chest Xray E. Do nasal swabs with PCR testing or bacterial culture and prescribe oral dexamethasoneQ UEST ION 2 • A 6 year-old boy presents with a history of repeated respiratory infections since birth. His birth was, however, uncomplicated. His mother claims that he's not growing as he should for his age and struggles with loose stools and bloating. What is the most likely diagnosis? A. Klinefelter syndrome B. Primary Ciliary Dyskinesia C. Cystic Fibrosis D. Chronic lung Disease of prematurity E. Likely due to caretaker negligenceQ UEST ION 2 • A 6 year-old boy presents with a history of repeated respiratory infections since birth. His birth was, however, uncomplicated. His mother claims that he's not growing as he should for his age and struggles with loose stools and bloating. What is the most likely diagnosis? A. Klinefelter syndrome B. Primary Ciliary Dyskinesia C. Cystic Fibrosis D. Chronic lung Disease of prematurity E. Likely due to caretaker negligenceQ UEST ION 3 A 4-year-old boy is brought to the emergency department with symptoms of lethargy, cough and breathlessness that have been present for the past 2 weeks. The mother reports that the cough has been progressively worsening. Upon examination, the child has a fever, tachycardia and tachypnoea. Given the age and worsening cough, the suspected infecting organism is Mycoplasma pneumonia. A chest x-ray confirms right lower zone consolidation. What is the most appropriate oral therapy for this patient? A. Amoxicillin B. Benzylpenicillin C. Co-amoxiclav D. Erythromycin E. AciclovirQ UEST ION 3 A 4-year-old boy is brought to the emergency department with symptoms of lethargy, cough and breathlessness that have been present for the past 2 weeks. The mother reports that the cough has been progressively worsening. Upon examination, the child has a fever, tachycardia and tachypnoea. Given the age and worsening cough, the suspected infecting organism is Mycoplasma pneumonia. A chest x-ray confirms right lower zone consolidation. What is the most appropriate oral therapy for this patient? A. Amoxicillin B. Benzylpenicillin C. Co-amoxiclav D. Erythromycin E. AciclovirQ UEST ION 4 • A term infant delivered via C-section develops tachypnoea, grunting, flaring, and intercostal retractions 10 minutes after birth. A chest radiograph reveals well-aerated lungs with fluid in the fissure on the right, prominent pulmonary vascular markings, and flattening of the diaphragm. His oxygen saturation is 90%. He improves within a few hours and requires no oxygen. What condition is this infant most likely suffering from? A. Transient tachypnoea of the new-born B. Aspiration pneumonia C. Congenitally acquired pneumonia D. Meconium aspiration E. Pulmonary oedemaQ UEST ION 4 • A term infant delivered via C-section develops tachypnoea, grunting, flaring, and intercostal retractions 10 minutes after birth. A chest radiograph reveals well-aerated lungs with fluid in the fissure on the right, prominent pulmonary vascular markings, and flattening of the diaphragm. His oxygen saturation is 90%. He improves within a few hours and requires no oxygen. What condition is this infant most likely suffering from? A. Transient tachypnoea of the new-born B. Aspiration pneumonia C. Congenitally acquired pneumonia D. Meconium aspiration E. Pulmonary oedemaPOSSIBLE OSC E S TAT IONS 1. Respiratory Examination +(possible findings/questions) 2. History and explanation to parent about URTI and no need for antibiotics(insistent parent) 3. Prescribing Salbutamol (2.5 mg in <8 years,5 mg in >8 years) and oral prednisolone for child with acute asthma 4. New-born screening positive for Cystic Fibrosis – explain findings and management(screening test not confirmatory)Thank you ☺ Any questions (with this presentation or Med school and Fy1 in general, email me on sweathaananth@gmail.com)