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An approach to a child with resp

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An approach to a child with resp Powered By Docstoc
					An approach to a child with
respiratory symptoms

   Dr. Pushpa Raj Sharma
   Professor of Child Health
   Institute of Medicine
Common respiratory symptoms

        Cough             Chest pain
     Runny nose        Chest indrawing

     Tachypnoea          Haemoptysis

       Snoring       Bluish discoloration
        Stridor

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

                     Snoring

                     Grunting
                     Stridor

                     Wheeze
                     Ronchi
    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.
     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.
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
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.
Causes of Wheeze/Ronchi

   Bilateral                    Unilateral
       Asthma                       Pneumonia
       Bronchiolitis                Foreign body
       Mycoplasma                   Mediastinal mass
       Cystic fibrosis              Tuberculosis
       Alpha 1 antitrypsin          Bronchiectasis
        deficiency                   Vascualr ring
       Severe pneumonia
Chest Pain: Rarely cardiac origin in
children.
   Infective
       Pneumonia; pleural effusion, pneumothorax.
       Born Holm disease
   Asthma
   Trauma
   Costochondritis
   Psychogenic
   Pericardial lesions
The severe signs: Chest Indrawing and
Cyanosis
   Chest in drawing:                    Cyanosis:
       Increased airway                     Vasomotor instability in
        resistance.                           acrocyanosis.
       Contraction of diaphragm             Defective perfusion.
        and pulling of ribs inside.          Defective ventilation.
       Negative pressure inside             Defective diffusion.
       Breathing in and lower               Methhaemoglobinemia
        chest wall goes in.                  Hyperoxia test
       Supra sternal, inter costal
        recession.
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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posted:6/5/2010
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