Respiratory Disease In Childhood

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Respiratory Disease In Childhood

• Nick Connolly
• Paediatric SpR
• NHS Tayside

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Respiratory problems in children

• Neonatal respiratory problems
• Respiratory problems in older children
• Chronic
• Acute

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Scenario

• An infant born at 30 weeks gestation develops
  respiratory distress at age 2 hours

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Respiratory Distress Syndrome

• Relative Surfactant deficiency
• 1 all births
• Predominantly in preterm inverse relationship
  with gestation

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Surfactant

• Phospholipid
• Apoproteins
• Secreted at 30-32/40
• Lack of surfactant results in atelectasis and
  impairment of gas exchange
• Production stimulated by steroids

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Incidence of RDS relative to gestational age
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Further problems

• Ventilated
• Sudden deterioration requiring increased oxygen
• No breath sounds on the right side of chest

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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

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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

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Scenario

• New born full-term infant with severe
  breathing difficulty after birth
• ?Dextrocardia

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Diaphragmatic Hernia

• Incidence1/2400
• Associated pulmonary hypoplasia
• Commonest- Posterolateral (Bochdalek), left-sided
• Avoid bag-mask IPPV?
• Respiratory support
• Surgical

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Older Children
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Examination

• Weight(length/height)..plotted!
• ?clubbing
• Chest shape
• Auscultation

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Breathing tests
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Chronic problems
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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 ?F508 deletion

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Cystic Fibrosis

• Autosomal recessive
• Carrier incidence roughly 1 in 25 people
• Mutations in the CFTR gene
• Multisystem disorder
• Respiratory infections are prominent

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Differential diagnosis

• Immune deficiency
• Ciliary dyskinesia
• Asthma
• Kartageners/ immotile cilia syndrome- rare

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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

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Cystic Fibrosis Team

• Clinician
• Specialist nurse
• Clinical psychologist
• Social worker
• Physiotherapist
• Dietician

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A 7-year child presents to your clinic with a
3-month history of cough worse at night or during
active play

• Diagnosis ASTHMA

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Asthma Diagnosis in ChildrenSIGN 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

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Asthma Diagnosis in ChildrenSIGN 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

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Asthma Diagnosis in Children
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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

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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

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Acute problems
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Acute asthma

• Cough and wheeze worsening over hours or days

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Treatment

• Oxygen
• Nebulised bronchodilator
• Oral prednisolone
• IV salbutamol
• IV aminophylline
• IV magnesium
• Ventilatory support

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Scenario

• 6 week old presented with increased work of
  breathing and possible apnoes
• URTI symptoms over last 2 days

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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

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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

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Pneumonia

• Neonates GBS, E.coli, Klebsiella, Staph aureus
• Infants Strep pneumoniae, Chlamydia
• School age Strep pneumoniae, Staph aureus, Gr A
  strep, Bordetella, Mycoplasma, Legionella

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Scenario

• A 2-year old child presenting with barking
  cough and difficulty in breathing of sudden onset

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Differential Diagnosis

• Inhaled foreign body
• Laryngomalacia
• Epiglottitis and bacterial tracheitis
• Allergy
• Croup

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Croup

• Viral laryngotracheobronchitis
• Stridor, barking cough
• Treatment is oral steroid to reduce inflammation

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Scenario

• 9 month old infant from developing country with
  irritability, neck rigidity, afebrile

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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

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Common respiratory problems in children

• Infant respiratory distress syndrome
• CLD
• Congenital diaphragmatic hernia
• Cystic fibrosis
• Asthma
• Bronchiolitis
• Childhood pneumonias
• Croup
• Tuberculosis

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FINISHED