Respiratory Diseases

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Respiratory Diseases

• Lin Guangyu
• Department of Pediatrics, The Second Affiliated
  Hospital to Medical College, Shantou University

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General Introduction

• Respiratory diseases that include inflammation of
  upper and lower respiratory tract, allergic
  diseases, pleura diseases, foreign body,
  pulmonary tumors and congenital disorders is a
  significant cause of death and chronic illness in
  children.
• Pediatric pulmonary diseases account for almost
  50 of deaths in children under age 1 year and
  about 20 of all hospitalization of children
  under age 15 years.

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General Introduction

• Respiratory infections are the most frequently
  occurring illness in childhood.
• Pneumonia accounts for almost 28 of deaths in
  children under age 5 years.
• Approximately 7 of children have some sort of
  chronic disorder of the lower respiratory system

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• Pneumonia

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Classification

• Classified by anatomy
• Lobar Pneumonia
• Bronchopneumonia
• Interstitial Pneumonia
• Bronchiolitis

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Classification

• Classified by etiology
• Viral Pneumonia
• Respiratory Syncytial Virus (RSV )
• Adenovirus
• Rhinoviruses
• Parainfluenza or influenza viruses
• Enteroviruses
• Cytomegalovirus (CMV)
• Measles virus

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• Human metapneumovirus
• Human bocavirus
• SARS coronavirus

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About Human Metapneumovirus

• It is classified by paramyxovirus.
• It is about over 10 of all children with
• respiratory infection in winter.
• It is nearly not covert infection at all.
• It is one of the most important pathogens that
  cause the wheeze.
• It is mainly cause bronchopneumonia and
  bronchiolitis.

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About Human Bocavirus

• It is classified by parvoviridae.
• It is about 1.511.3 of all children with
• respiratory infection.
• It is one of the most important pathogens that
  cause the wheeze.
• It is mainly cause bronchopneumonia and
  bronchiolitis.
• Is it a pathogen?

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About coronavirus

• Type 1 Mammal
• Type 2 Mammal
• Type 3 Aves
• Type 4 SARS Coronaviruses

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Classification

• Bacterial Pneumonia
• Gram-positive coccus
• Streptococcus Pneumoniae
• Staphylococcus aureus ,CNS!
• Gram-negative bacillus
• Pneumobacillus
• Escherichia coli
• Pseudomonas
• Haemophilus influenzae
• Klebsiella
• Legionella pneumophila
• Anaerobe

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Classification

• Mycoplasmal pneumonia
• Mycoplasma pneumoniae
• Chlamydial pneumonia
• Chlamydia
• Fungal Pneumonia
• Cryptococcus
• Candida
• Coccidioides
• Histoplasma

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Classification

• Protozoal pneumonia
• Pneumocystis Carinii
• Noninfectious pneumonia
• Inhalation Pneumonia
• Eosinophilic pneumonia

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Classification

• Classified by course
• Acute Pneumonia lt1 month
• Deferred Pneumonia 13 months
• Chronic Pneumonia gt3 months

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Classification

• Classified by patients condition
• Mild pneumonia
• Severe pneumonia

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Classification

• Others
• Typical pneumonia
• Atypical pneumonia
• Pneumonia caused by SARS coronavirus
• Community acquired pneumonia (CAP)
• Hospital acquired pneumonia (HAP)

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• Bronchopneumonia

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Introduction

• Bronchopneumonia, accounting for 24.556.2 of
  all hospitalizatons of children, is the most
  frequently occurring illness in childhood.
• The incidence is higher in early childhood than
  in any other period of life.
• There are significant difference in the incidence
  of bronchopneumonia by season and geographic
  region.

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Etiology

• Most pneumonia in children are caused by viruses
  and bacteria.
• Viruses
• RSV
• Parainfluenza viruses (1, 2 and 3)
• Influenza viruses (A and B)
• Adenovirus
• RSV, parainfluenza and influenza are responsible
  for more than 75 of cases.

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Etiology

• Bacteritic
• Streptococcus Pneumoniae (the most common cause
  of bacterial infection)
• Staphylococcus aureus ,CNS
• Haemophilus influenzae
• Klebsiella
• Pneumobacillus
• Escherichia coli
• Pseudomonas
• Mycoplasma pneumoniae

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Different organisms affect different
age groups Age Bacterium
Virus
others 1d-20d Group B H
Streptococcus Cytomegalovirus
Gram-negative bacilli(E.coli)
3w-3m Streptococcus pneumoniae
RSV Chlamydia
trachomatis Bordetella
pertusssis Parainfluenza virus
Staphylococcay aureus 4m-4y
Streptococcus pneumoniae RSV
Mycoplasma pneumoniae
Haemophilus influenzae
Parainfluenza virus
Mycobacterium tuberculosis Influenze virus

Adenovirus

Rhinoviruses 5y-15y Streptococcus
pneumoniae
Mycoplasma pneumoniae

Chlamydial
pneumonice
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Etiology

• Other causes
• Age
• Season of the year
• Immune status of the host
• Environmental factors

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Pathology

• Inflammatory cell infiltration, exudate, edema
  and localized hemorrhage of bronchiolar
  submucosa, Interstitium, alveoli, Interalveolar
  septa and lymphatic vessels
• Necrosis of bronchiolar and alveolar epithelium
• Hyperinflation or collapse of the distal lung
  tissue

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Pathology

• Lesions of viral or bacterial infection result
  in tracheitis, bronchitis, interstitial pneumonia
  and lobuli pneumonia.
• Interstitial involvement is relatively common in
  viral pneumonia.
• Bacterial pneumonia is characterized by the
  presence of damages of lung tissue.

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Pathophysiology

• Respiratory disorder (acute respiratory failure)
• Ventilation and /or perfusion disorder (V/Q
  mismatch)
• Diffusion defects
• Intrapulmonary shunt

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Pathophysiology

• Circulatory disorders
• Viral and/or toxipathic myocarditis
• Pulmonary hypertension
• Heart failure
• Circulatory failure ( shock)
• Disseminated intravascular coagulation (DIC)

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Pathophysiology

• Anomalies of central nervous system
• Cerebral edema (toxic encephalopathy)
• Hypoxemia
• Hypercapnia
• Metabolic Acidemia
• Energy metabolism disorder
• Toxin

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Pathophysiology

• Anomalies of Alimentary system
• Toxic enteroparalysis
• Gastrointestinal bleeding
• Hypoxemia and hypercapnia
• Abnormalities of electrolyte balance
• Toxaemia
• shock
• Acute stress ulcer
• Hepatic injury

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Pathophysiology

• Acute renal failure
• Adrenal crisis (insufficiency)
• Abnormalities of water, electrolyte and pH
  balance
• SIRS?MODS?MOF

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Bronchia mucosa edema
Alveolus edema
air exchange
air entry
Respiratory failure
Metabolic acidosis
Respiratory acidosis
toxic encephalopathy
Gastrointestinal breeding
Heart failure
Toxic enteroparalysis
Toxaemia
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Clinical Manifestations

• Symptoms and sings
• General symptoms and sings
• Fever
• Body temperature is higher in bacterial infection
  than viral infection
• Hypothermia (infant)
• symptoms and sings of generalized toxicity
• Myalgia, Malaise and headache

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Clinical Manifestations

• Symptoms of respiratory system
• Cough
• Dry cough
• Productive cough
• Tachypnea
• Dyspnea
• Rapid, shallow respirations( 4080/ min)
• Nasal flaring
• Intercostal, subcostal, and suprasternal
  retraction
• Cyanosis
• Respiratory fatigue

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Clinical Manifestations

• Signs of respiratory system
• Widespread moist rales and wheezing
• Signs of substantial variations
• Decreased breath sounds
• Dullness to percussion
• diminished tactile or vocal fremitus
• Bronchial breath sounds

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Clinical Manifestations

• Severe Pneumonia
• Circulatory system
• Rival or toxic myocarditis
• Heart failure

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Heart failure

• Rapid, shallow respirations60/min
• Rapid heart rates 180/min
• Dyspnea with intercostal and subcostal
  retractions, cyanosis, pale and gray of face ,
  irritability, and peripheral pallor
• Muffled and distant heart sounds, and a gallop
  rhythm
• Liver enlargement
• Edema of the face and extremities,oliguria or
  anuria

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Clinical Manifestations

• Nervous system
• Toxic encephalopathy
• Alimentary system
• Toxic enteroparalysis
• Gastrointestinal bleeding
• DIC
• SLADH
• MODS

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Complications

• Empyema
• Pneumothorax
• tension pneumothorax
• Pyopneumothorax
• Pneumatocele

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Laboratory Test

• Tests for etiologic agent
• Bacterial culture
• Blood culture
• Culture of material from the respiratory tract
  secretion
• Culture of Pleural effusion
• Other culture

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Laboratory Test

• Laboratory diagnosis of viral infections
• Antigen or nucleic acid detection
• Isolation of viruses by culture of the
  respiratory tract secretions
• Use of special antibodies

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Laboratory Test

• Isolation and culture of other etiologic agent
• Mycoplasma pneumoniae
• Chlamydia
• Fungi
• Specific antibody detection on the pathogens
• Tests of molecular biology
• DNA probs
• Polymerase chain reaction (PCR)

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Laboratory Test

• Blood test
• White blood cell counts
• Bacterial pneumonia ??
• Rival pneumonia?
• NBT test
• NBT-positive cellsgt10
• C-reactive protein (CRP)
• CRP 15µg/ml
• Blood gas analysis

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Chest X-ray Findings

• Perihilar streaking
• Increased interstitial markings
• Peribronchial cuffing
• Patchy infiltrates in the lung
• Development of pneumatoceles
• Hyperinflation of the lung
• Atelectasis
• Lobar consolidation (as in bacterial pnuemonia)
• Radiographic findings of pleural effusion

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Diagnosis and Differential Diagnosis

• Diagnosis
• According to symptoms, signs, and Radiographic
  findings, bronchopneumonia are easily diagnosed.
• A key decision in evaluating children with
  bronchopneumonia is to determine whether the
  illness is mild or severe, or whether a secondary
  infection or complication is present

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Diagnosis and Differential Diagnosis

• Differential Diagnosis
• Acute bronchitis
• Pulmonary tuberculosis
• ?Acute miliary tuberculosis of the lungs
• Foreign body in bronchus

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Acute bronchitis
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Acute miliary tuberculosis of the lungs
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Acute miliary tuberculosis of the lungs
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Foreign body in bronchus
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Treatment

• General treatment
• Humidification of inspired gases
• Hydration and electrolyte supplementation
• Oral hygiene
• Nutrition

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Treatment

• Etiological treatment
• Antibiotic therapy
• It is not possible to differential reliably
  between bacterial or viral pneumonia on clinical
  or radiological grounds ,so all children
  diagnosed having pneumonia should be giving
  antibiotics as the pathogen is rarely known when
  treatment is started.

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Treatment

• Before the pathogen is identified, therapy of
  patients is determined by the pattern of disease
  and the organisms that are common for age of the
  children .
• Community-acquired bacterial infection
• Nosocomial infection acquired in the hospital

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The choice of antibiotic is determined
by ages Age Out-patients
In-patients(Intravenous)
(oral) Less severe
Severe 1-20d
Ampicillin
AmpicillinCefotaxime

AmpicillinCefotaxime 3w-3m Erythromycin
Erythromycin
Cefotaxime Azithromycin
Erythromycin Cefotaxime 4m-4y
Amoxicillin Ampicillin
Cefotaxime

Ceforoxime 5y-15y Erythromycin
Erythromycin Cefotaxime
Clarithromycin
Azithromycin Cefuroxime
Azithromycin
ErythromycinAmpicillin CefotaximeAzithrom
ycin
Azithromycin Ampicillin
CefuroximeAzithromycin
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Treatment

• Oral antibiotics (e.g. co-amoxiclav or a
  second-generation cephalosporin such as cefaclor)
  can given for less severe pneumonia.

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Treatment

• If intravenous therapy is requried,activity
  against pneumococci, H.influenzae and Staph
  aureus can be achieved with a cephalosporin(e.g.ce
  fotaxime, ceftriaxone, cefuroxime, cefazidime )

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Treatment

• Therapy for most patients should be continued for
  a total of 57 days after body temperature is
  normal, or at least 3 days after clinical
  symptoms has disappeared.
• The course of treatment for staphylococcus aureus
  is usually for 6 weeks
• Treatment for Mycoplasmal pneumonia is usually
  for 23 weeks.

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Treatment

• Once the pathogen has been identified
  and the antibiotic sensitivities determined, the
  most appropriate drugs should selected.

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The choice of antibiotic is determined by
organisms(1) Organisms
First choice
Second choiceStrept pneumoniae
Pnicillin G
Ceftriaxone
Cephlosporins
Cefotaxime
(1st or 2nd generation)
Vancomycin H. influenzae
AmoxicillinClav Acid
Cephlosporins
Amoxicillin Sulbactam
(1st or 2nd generation)


Macrolides

(New generation)Staphylococeus MSSA
MSSE Oxacillin
Cephlosporins
Claxacillin
(1st or 2nd generation)
MRSA MRSE Vancomycin

RifampineM.catarrhalis
AmoxicillinClav Acid Macrolides


(New generation)

Cephlosporins

(1st or 2nd
generation)
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The choice of antibiotics is determined by
organisms(2) Organisms
First choice Second
choiceEnteric bacilli Ceftriaxone
TicarcillinClavulani
c Acid
(Amikacin) Azfreonam
Cefotaxime
Imipenem

4th generatim Cephlosporins
P.aeruginose TicarcillinClav.Acid
AMKAzfreonam
PiperacillinTAZ
Imipenem
Mezlocillin
Ceflazidime
CefoperazoneSulperazon
CefepimeAMKGBS
Penicillin G(LD)
Amoxicillin
Ampicillin
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Treatment

• If staphytococcal aureas or CNS
  pneumonia is suspected, Penicillin, Clindamycin,
  Vacomycin (one of them ) is given.

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Treatment

• If M.pneumoniae or
• Ch.trachomatis pneumonia is suspected,
  erythromycin is given.

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Treatment

• Anti-viral therapy
• Ribavirin
• Interferons
• Poly IC

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Treatment

• Heteropathy
• Oxygen therapy
• Maintaining free airway
• Treatments for heart failure
• Treatments for toxic enteroparalysis
• Treatments for respiratory failure
• Treatments for shock
• Treatments for toxic encephalopathy

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Treatment

• Treatments for heart failure
• Oxygen inhale
• Sedation
• Cardiotonic
• Diureses
• Drugs of dilating blood vessel

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Treatment

• Treatments of toxic encephalopathy
• Oxygen inhale
• sedation
• Pyretolysis
• Subhibernation
• Anhydration
• 20Mannitol 1.55ml/kg /does q6h

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Treatment

• Application of cortical hormone
• Indication
• Severe pneumonia
• Superhigh fever
• Severe toxic symptoms
• Wheezing
• Shock, toxic encephalopathy, Cerebral edema, and
  respiratory failuer
• pleural effusion

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Treatment

• Treatments for complications
• Repeat pleural taps for remove of pleural fluid

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Clinical Teafures of Pneumonia due to Some
Pathogen

• Rspiratory syncytial virus pneumonia
• Adenovirus pneumonia
• Staphylococal aureus pneumonia
• Gram-negative bacillary pneumonia
• Mycoplasma pneumonia
• Chlamydial pneumonia

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Respiratory snycytial virus pneumonia

• Diffuse wheezing and tachypnea following upper
  respiratory symptoms in an infant (age ltone
  year).
• Epidemics in late fall to early spring .
• Hyperinflation on chest X-ray.
• RSV antigen detected in nasal secretions.
• 30-40 of patients hospitalized with this
  infection will wheeze later in childhood.

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Adenovirus pneumonia

• Severe pneumonia may occur at all ages. It is
  especially common in young chillren
  (agelt6months2years).
• Chest X-rays show bilateral peribronchial and
  interstitial infiltrates.
• Symptoms include high fever, respiratory
  symptoms, diarrhea, encephalitis, hepatitis and
  myocarditis may persist for 2-3weeks.
• Can be necrotizing and cause permanent lung
  damage, especially bronchiectasis.

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Staphytococcal aureus pneumonia

• This pneumonia is characterized by abdominal
  distention, high fever, respiratory distress, and
  toxemia.
• It often occurs without predispossing for factors
  or after minor skin infections.
• Pneumotoceles, pyopneumothora, and empyema are
  frequently encountered.
• Rapid progression of disease is characteristic.
• Frequent chest X-rays to monitor the progress of
  disease are indicated.
• WBC??

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Myeoplasma pneumoniae pneumoia

• Essentials of diagnosis typical festures
• Fever
• Cough
• Appropriate ageover5year
• Endemic and epidemic infection can occur.
• The incubation period is long(2-3weeks).and the
  onset of symptoms is slow.
• Extrapnlmonary complications sometimes occur.
• Chest X-rays usually demonstrate interstitial or
  bronchopneumonia infiltrates, frequently in the
  middle or lower lobes.

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Chlamydial pneumonia

• Cough, tachypneu, rales, few, wheezes, and no
  fever.
• Appropriate age212weeks.
• Inclusion conjunctivitis, eosinophilia, and
  elevated immunoglobulins can be seen.
• Chest X-rays may reveal diffuse interstitial
  thickening, or focal consolidation.

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Avian influenza in human beings

• Due to the infection of HPAI virus ( highly
  pathogenic avian influenza ,type H5N1).
• Characteristic syndrome of sudden onset of high
  fever,severe myalgia, headache and chills.
• Diarrhea, vomiting, and MOF, DIC are common.
• High case fatality rate (over 3067)

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Questions
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• How to diagnose pneumonia in children?

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• What is severe pneumonia in children?

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• How to consider the etiology of pneumonia
  in children?

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• What is your opinion about pneumonia
  complicate with heart failure in children?

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Heart failure

• Rapid, shallow respirations60/min
• Rapid heart rates 180/min
• Dyspnea with intercostal and subcostal
  retractions, cyanosis, pale and gray of face ,
  irritability, and peripheral pallor
• Muffled and distant heart sounds, and a gallop
  rhythm
• Liver enlargement
• Edema of the face and extremities,oliguria or
  anuria

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REFERENCES

• 1.?????. ???.???.2005
• 2.Tom L. Paediatrics.2nd.2002
• 3.???,?.????.???.2007