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An approach to a child with respiratory symptoms

An approach to a child with respiratory symptoms. Dr. Pushpa Raj Sharma Professor of Child Health Institute of Medicine. Cough Runny nose Tachypnoea Snoring Stridor Wheeze. Chest pain Chest indrawing Haemoptysis Bluish discoloration. Common respiratory symptoms.

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An approach to a child with respiratory symptoms

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  1. An approach to a child with respiratory symptoms Dr. Pushpa Raj Sharma Professor of Child Health Institute of Medicine

  2. Cough Runny nose Tachypnoea Snoring Stridor Wheeze Chest pain Chest indrawing Haemoptysis Bluish discoloration Common respiratory symptoms

  3. The most important sign: Tachypnea • Cut off rate per minute • Less than 1 week up to 2 months: 60 or more • 2 months up to 12 months: 50 or more • 12 months up to 5 years: 40 or more. • Pathophysiology: • Hypoxaemia • Pulmonary oedema • Parenchymal inflammation • Restricitve/obstructive diseases

  4. The most severe sign: Apnoea • Acute life threatening event: • Apnoea > 20 second or associated with pallor, cyanosis, convulsion or limpness. • Aetiology: • Prematurity • Sepsis • Meningitis/encephalitis • Drugs • Abnormal muscle tone

  5. Cough • Commonest respiratory symptom. • Physiological to remove excess secretions or foreign body. • Cough receptors in the posterior pharynx and large bronchi. • Vagus/ glossopharyngeal: afferent to cough centre –pons /medulla. Efferent to - larynx/ diaphragm/ chest wall/abdominal wall/pelvic • Acute: lasts less than 2 weeks. • Chronic: lasts more than 2 weeks.

  6. Cough relating to time/ posture • During or after feeding: aspiration • Night: asthma/ post nasal drip • Morning: bronchiectasis • With exercise: asthma • Absence during play: psychogenic • Seasonal: allergen • Cold: hyperreactivity

  7. Infants: Infections Chlamydia Pertussis Bronchiolitis Non infectious Asthma Domestic smoke pollution/passive smoke Gasro-eso. Reflux Foreign body Congenital anamolies Tracheo-eso. fistula Children Infectious Pneumonia Croup Post nasal drip/sinusitis Non infectious Asthma Foreign body Tropical eosiniphilia Environmental irritants Psychogenic Differential diagnosis of chronic cough

  8. Treatment of chronic cough • Over the counter cold preparation: • no beneficial effect in children under 5 years. • Post nasal drip: • Propped up position at 30 degree. • Treat accordingly for Allergic/non allergic rhinitis; Sinusitis • Macrolides: if Mycoplasma / chlamydia suspected. • Nasal steroids/ decongestant • Bronchodilators/ steroids • Specific treatment

  9. Psychogenic Cough • School aged children. • The child is often a high achiever; family stress • Fixed timing but disappears during sleep and when distracted. • Diagnosis by observation and exclusion of other causes. • Treatment: Counseling, Normal saline gargle

  10. Snoring Grunting Stridor Wheeze Ronchi Noisy Breathing

  11. Snoring • Inspiratory harsh sound irregularly • Associated with: large tonsils and adenoids; micrognathia, macroglossia, palatal palsy, pharyngeal hypotonia, obesity • Diagnostic test: • Sleep study, flexible bronchoscopy, lateral x-ray neck • Treatment needed if: • Sleeping difficulty; daytime somnolence, enuresis, growth failure, morning headache.

  12. Stridor • Inspiratory harsh sound continuously. Can occur during expiration (intrathoracic) or both phase of respiration. • Asses the severity • Drooling of saliva, respiratory distress, unable to swallow, cyanosis • Common causes: • Infective: epiglottitis, laryngotracheobronchitis, tracheitis, retropharyngeal abscess (rare) • Malignancy: tumor compression, papilloma • Allergic: angioneurotic oedema. • Congenital: laryngomalacia, laryngeal web, vascular ring, • Aspiration: foreign body. • Neuronal: paralysis of vocal cord. • Investigation • Blood count; Lateral neck X-ray; flexible bronchoscopy.

  13. Grunting • Low pitched expiratory sound. • Protective phenomenon to prevent collapse of alveoli: PEEP • Causes: • Respiratory distress syndrome • Severe pneumonia, ARDS, severe sepsis • Investigations: • CXR; O2 saturation, blood gas

  14. A child who wheezes: All wheezes are not Asthma • Cough could be the only symptom. • Triggering factor • Worse at night • History of repeated problem. • Symptomatic improvement with bronchodilator. • Gastro-esophageal reflux: Prokinetic.

  15. Bilateral Asthma Bronchiolitis Mycoplasma Cystic fibrosis Alpha 1 antitrypsin deficiency Severe pneumonia Unilateral Pneumonia Foreign body Mediastinal mass Tuberculosis Bronchiectasis Vascualr ring Causes of Wheeze/Ronchi

  16. Chest Pain: Rarely cardiac origin in children. • Infective • Pneumonia; pleural effusion, pneumothorax. • Born Holm disease • Asthma • Trauma • Costochondritis • Psychogenic • Pericardial lesions

  17. Chest in drawing: Increased airway resistance. Contraction of diaphragm and pulling of ribs inside. Negative pressure inside Breathing in and lower chest wall goes in. Supra sternal, inter costal recession. Cyanosis: Vasomotor instability in acrocyanosis. Defective perfusion. Defective ventilation. Defective diffusion. Methhaemoglobinemia Hyperoxia test The severe signs: Chest Indrawing andCyanosis

  18. Haemoptysis: not common • Blood from posterior naso-pharynx or hematemesis: the difference. • Aetiology: • Bronchiectasis. • Severe cough • Pneumonia • Paragonimiasis • Foreign body • Severe measles • Haemangioma/ AV malformation

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