Download Obstructive respiratory diseases

Obstructive respiratory diseases
Mária Adonyi
Pediatric Clinic, University of Pécs
NARROWINGS IN
THE
NASOPHARYNX
NARROWINGS IN
THE PHARYNX
Choanal atresia
Macroglossia
Adenoid vegetation
Tonsillar hypertrophy
Teratomas
Haemangioma
Tumors
Lymphangioma
Foreign body
Retropharyngeal absc.
GLOTTIC
NARROWINGS
Vocal cord paresis
Granulation tissue
Papillomatosis
SUBGLOTTIC
NARROWINGS
Congenital
Acquired (post-intubation)
SUPRAGLOTTIC
NARROWINGS
Epiglottitis
Congenital inspiratory
stridor
Cysts
TRACHEO- BRONCHIAL NARROWINGS
Congenital
or
acquired
- Extramural – compression
vascular ring, cyst, lymph node, tumor
cause irreversible cartilage degeneration
- Mural – cartilage weakness , tracheomalacia
- Intramural
foreign body, granulation tissue, scars,
discharge, tumor
DIAGNOSIS OF STRIDOR
History taking
Physical examination
Radiological diagnosis
Endoscopic procedures
RESPIRATORY INFECTIONS
• Common cold
• Acute otitis media, sinusitis
• Pharyngitis, tonsillitis, diphteria
• Whooping cough
• Laryngo-tracheo-bronchitis (Croup sy)
• Epiglottitis
• Acute bronchitis
• Bronchiolitis
• Pneumonia
In children under the age of 5, 50% of diseases
are acute respiratory infections.
CROUP SYNDROME
acute laryngo-tracheo-bronchitis
Acute viral infection characterized by : a
barking cough, inspiratory stridor, hoarseness,
caused by subglottic stenosis.
• inspiratory stridor lasting for hours
• usually occurs at night
• the child has no fever
• does not seem to be sick
Etiology:
Human parainfluenza virus type 1,2,3, RSV,
Adenovirus, Influenza virus A and B, Enterovirus,
Mycoplasma pneumoniae
It predominantly occurs in the first 3 years of age. It is
most prevalent in late autumn or winter at the age of 2.
Differential diagnosis:
- Congenital stridor,
- Bacterial epiglottitis, tracheitis, diphteria
- Foreign body, etc.
Croup severity score
Croup score
0
1
2
Stridor
none
Inspiratory
In- and expiratory*
Retractions
none
Nasal flaring and
suprasternal retraction
Sternal, sub-,
intercostal*
Air entry
Normal
Cyanosis
Normal
Cyanosis at room
temperature
Cyanosis 40% O2
Alertness
Normal
Agitated
Depressed
Decreased
Severely decreased
*it can be absent if the patient is exhausted and breathing is
decreased
score < 5 mild
score 5-6 mild/moderate (emergency care depending on symptoms)
score 7-8 moderate/severe (ICU necessary)
score > 8 severe (ICU)
What is to be done?
if score < 7:
Calm the child.
Nebulized epinephrine, Tonogen
Steroid
Di Adreson inj 1-2 mg/kg i.m, iv.,
Dexamethasone: 0.6mg/kg im. or iv., Prednisone supp.
Fluticasone (Flixotide EH) inhaled steroid
Cold humidified air (mist).
Adequate fluid intake.
Monitoring .
After improvement the patient can be discharged.
Epiglottitis
Acute life-threatening bacterial infection, which
causes cellulitis and oedema of the epiglottis and plica
aryepiglottica, hypopharynx , and results in a
narrowing.
Checking the throat might
induce apnoea.
Etiology
Haemophilus influenzae B (more than 90% - before
the vaccination period)
Staphylococcus aureus, Streptococcus pneumoniae,
Streptococcus pyogenes, candida
Between the ages of 2 - 6 , regardless of seasons
Reduced by 98% since the vaccination.
Differential diagnosis
croup, peritonsillar abscess, retropharyngeal abscess,
foreign body, laryngitis
Lab:elevated WBC count, high CRP
Therapy
· Keep the child as comfortable as possible.
· Oxygen supplementation, oxygen mask
· Specialist consultation (anaesthesiologist,
ENT specialist, pediatrician)
· to perform intubation in the operating room.
· Cricothyrotomy if intubation is not possible.
· Medications: 3. generation cephalosporins
(ceftriaxone, cefotaxime).
Ampicillin (100-200 mg/kg/day) and
chloramphenicol (75-100 mg/kg/day)
Clinical characteristics differentiating
laryngotracheobronchitis (LTB) from epiglottitis
LTB
Epiglottitis
Age
6 months-3 years
2-6- yr
Onset
Gradual
Rapid
Etiology
Viral
Bacterial
Swelling
Subglottic
Supraglottic
Cough-voice
Hoarse cough
No cough
Stridor
Inspiratory
Inspiratory
Posture
Any position
Sitting (tripod)
Mouth
Closed: nasal flaring
Open chin forward,
drooling
Fever
Absent to high
High
Appearance
Often not acutely ill
Anxious, acutely ill
Bronchiolitis
• The most common lower respiratory infection
in infany (3-6 months)
• The most common cause of hospitalizations < 3
months of age
• Risk factors:
under12 weeks of age,
prematurity,
previous cardiorespiratory disease
(mortality >30%),
immune deficiency
Crowded living conditions, History of atopic diseases,
Cigarette smoke
Etiology
• RSV - 75%, Adenovirus ( 7, 21 type), Rhinovirus,
Myxovirus, Parainfluenza, Human Metapneumovirus
Mycoplasma pneumonia, Chlamydia trachomatis <12weeks
Pathophysiology
The desquamative inflammation of the airways.
Diagnosis
• Medical history taking
• Physical examinations
X ray, laboratory examinations are not necessary routinely.
Symptoms
Runny nose, cough, tachypnoe, dyspnoe, wheezing,
chest wall retraction, ronchi and crackles, hypoxia
worsening condition due to respiratory muscle fatigue
Treatment
- Oxygen ( warmed, humidified ),
oxygen box <90% O2 SAT
- symptomatic
There is no evidence for the effects of
beta 2 mimeticum, steroid, aminophyllin.
- Monitoring transcutan oxygen level.
Hypercapnia ( mismatch of ventillation-perfusion )
above pCO2 60Hgmm - ventillation.
- Breastfeeding, feeding until it is possible.
Antibiotics are not recommended.
Differential diagnosis
• Pneumonia
• Cystic fibrosis
• Heart failure
• Congenital abnormalities
Obstructive bronchitis
Causes: viral infections
Bronchitis spastica, bronchitis asthmatica, wheezy bronchitis
„WHEEZING” PHENOTYPES
• transient early wheezers
• non-atopic wheezers
• IgE-associated wheezy/asthma
Obstructive bronchitis
Wheezing and cough induced by infection above the age of 1 .
Etiology:
rhinovirus, influenza virus, Mycoplasma pneumoniae,
Str.pneum., Staphylococcus, Haemophilus influenzae
Differential diagnosis:
Treatment:
Bronchial asthma
Beta-2 agonists
Pneumonia
Inhaled steroid
Aspiration
Antibiotics if necessary
GERD
Bronchial asthma
Chronic inflammatory disease, bronchial
hyperreactivity.
Recurrent wheezing attacks and cough
especially during the night or early morning.
Intermittent airflow obstruction.
Factors triggering asthma:
allergens
infections
physical exercise
air pollution
cigarette smoke
psychic factors
western lifestyle etc.
Asthma phenotypes
Identifying Clinical Phenotypes in Children >2 Years
With Asthma
Is the child completely well
between symptomatic periods?
Yes
Are colds the most
common
precipitating factor?
No
No
Is exercise the
most common or
only precipitating
factor?
No
Does the child have
clinically relevant
allergic sensitization?
Yes
Yes
Yes
None
Virus
induced
asthmaa
Exercise
Induced
asthmaa
Allergen
induced
asthma
Unresolved
asthmaa,b
Children may also be atopic
etiologies – including irritant exposure and as yet not evident allergies, may be included here.
Bacharier LB, et al. Allergy. 2008;63(1):5–34.
a
b Different
The complex interaction of genes and
environmental factors modify the gene
expression and the phenotype already in the
early developmental stage.
Diagnosis:
 Chest X ray - hyperinflated lungs and depressed
diaphragm.
 Skin Prick Test – atopy
 Serum total IgE level - IgE antibody test
 Lung function test - reversible decrease in FEV1broncholysis test
 Bronchial provocation tests specific and non-specific
 Treatment – Add-on therapy
Treatment of acute asthma attack:
• Beta-2 agonist MDI: 2-4 puffs salbutamol with spacer device
every 10-20 minutes for one hour.
No effect: hospitalization
• Beta -2 agonist neubilized: 2,5-5 mg salbutamol equivalent
every 20-30 minutes.
• Supplementary ipratropium bromid : 250ug/dose
every 20-30 minutes.
• Maintaining appropriate oxygen level.
• Oral or iv. steroid 1-2mg/kg min. 3-5 days.
• Infusion of Beta-2 agonist.
Not all wheeze is asthma!
Differential diagnosis is essential !
Other diseases which cause obstruction:
croup - syndrome
recurrent bronchitis, pneumonia
foreign body aspiration
bronchial narrowing
congenital abnormalities
bronchiectasia
cystic fibrosis
heart failure
GERD
Improving neonatal care and survival
resulted in new problems in infants.
New type of BPD
Critical period of birth.
Obesity – increased risk of asthma
> 40 millions of obese children < 5 years of age
Obesity - dyspnoea = asthma, asthma like symptoms
Proinflamm. mediators: adiponektin, leptin
Respiratory inflammation mediated by leukotrien,
causes steroid resistance.
Comorbidity: GERD, OSA,
cardio-vascular diseases, metabolic disorders