Paediatric Respiratory Disease Rory Brittain

Outline  Airway Anatomy  Paediatric Considerations  Airway Infections  Cystic Fibrosis  Asthma

Paediatric Anatomical Variation  Intercostal muscles are not fully developed until school age. The muscles of the diaphragm are insert horizontally to the ribs, as opposed to obliquely.  While laying supine neck flexion can obstruct the airway.  Infants and younger children are predominantly nose breathers.

Normal Values Respiratory Rate  Neonates 30-50Tachypnoea >60  Infants20-30>50  Young Children20-30>40  Older Children15-20>30 Heart Rate  <1yr  2-5yrs  5-12yrs  >12yrs60-100

Paediatric Respiratory Distress  Clinical Signs  Tachypnoea  Tachycardia  Increased work of Breathing  Subcostal, intercostal and sternal recessions.  Grunting, nasal flaring  Tracheal Tug and Head bobbing.  Stridor or Wheeze  Cyanosis  Reduced Consciousness  Difficulty Feeding  Poor Respiratory Effort  video video

Paediatric Pneumonias  Inflammation of lung Parenchyma  More likely viral in younger children, bacterial in older children  Newborns – Infections from mothers genital tract Group B Streptococcus, g-ve enterococcus.  Infants – RSV, Strep. pneumoniae, Haemophilus influenza  >5yrs – Strep. pneumoniae, mycoplasma pneumoniae, chlamydia pneumoniae.  TB – All age Groups.  Sx – SOB, Cough, Wheeze, Fever, lethargy, Respiratory Distress  Rx – Oxygen, Fluids, Antibiotics

Bronchiolitis  Most common Serious respiratory infection of infancy  Causes – RSV (80%) Parainfluenzaviruses adenoviruses  Winter Epidemics, often preceded by URTIs  Epithelial necrosis and shedding, oedema and airway obstruction  <18ms peak incidence Nov-April  Sx – Breathlessness, Dry Cough, Wheeze  Serious Disease – signs of respiratory distress, hyperinflation of chest, cyanosis  0 2 Via nasal cannula  Bronchiolitis Obliterans – Irreversible complication

Whooping Cough  Bordatella pertussis bronchiolitis  Vaccinations - 2m,3m,4m & 40m (This does not provide Immunity!)  Epidemics every 2-3 years. Highly Infectious  Can be fatal in very young.  Typical 6 week course  1-2weeks Catarrhal phase – coryza  3-6 Paroxysmal Phase – Spasmodic dry “whooping” cough  May cause vomiting, epistaxis, sub-conjunctival haem.  Ix: Nasal Swab, Lymphocytosis  Rx: Erythromycin. Also prophylactically for close contacts.

Laryngotracheobronchitis (Croup)  Mucosal inflammation and swelling due to laryngeal/tracheal infections can cause life threatening obstructions of the airway in children.  Sx – Dyspnoea, Hoarseness, Stridor, Barking cough. Respiratory Distress.  Severity best assessed by degree of chest retractions and stridor.  Do not examine the Throat!  If severe give nebulised epinephrine +/- Steroids  Intubation/ Tracheostomy may be required.

Croup  95% of Viral larygotracheal infections are due to viral croup – 75% parainfluenzaviruses (also RSV, metapneumovirus and Influenza)  Low threshold for admission <12ms  Oral or nebulised steroids +/- epinephrine  Bacterial Tracheitis or pseudomembranous croup is similar except with high fever, and thick airway secretions. Caused by Staph. aureus. Treat with IV abx and intubation

Acute Epiglotitis  Life threatening emergency  Infection of epiglottis by Haemophilus influenzae type B (Hib)  Vaccination at 2,3,4, &12 months.  Most common between 1-6yrs  Important to differentiate from viral croup!  No preceding Coryza  Onset over hours rather than days  Cough absent or much less severe  Softer stridor  Unable to drink  May be drooling  High Fever  Muffled Voice, reluctant to speak  Appear toxic and very unwell  Urgent Intubation and IV cefuroxime

URTIs  80% of all RTI’s in children, often viral and self limiting.  Can affect feeding in very young children  May cause exacerbations of Asthma  Common Cold (Coryza) – Rhinovirus  Sore Throat (Pharyngitis) – Usually viral, Strep. Pneumoniae  Tonsilitis – 2/3 Viral (EBV) or. β -haemolytic strep.  Sinusitis – Usually Viral  Otitis Media

Cystic Fibrosis  Commonest life-limiting autosomal recessive condition in Caucasians. - 1/2500 births. 1/25 are carriers.  Defective CF transmembrane conductance regulator (CFTR) cAMP dependant chloride channel.  Abnormal ion transport across epithelial cells. Leads to impairted mucocillary clearance  Chronic Infection - Pseudomonas aerungiosa  Impaired Inflammatory response  Thickening of Meconium- Meconium Ilieus  Blockage of Pancreatic Ducts – Enzyme Deficiency and Malabsorption

CF - Clinical  Majority Picked up on screening – Heel Prick (Guthrie Test)  Recurrent Chest Infections  Bronchictasis and Abcess formation  Poor Growth, Malabsorption  Persistent Productive Loose Cough  Hyperinflation of chest  Crepitations and wheeze  Clubbing  Pancreatic Insufficency  Meconium Ileus  Respiratory Failure

CF Management  Diagnosis – Chloride Sweat Test  Genetic Testing (Immunoreactive trypsinogen (IRT))  Physiotherapy  Regular Lung Function Tests (FEV 1 )  Prophylactic Abx (Flucloxacillin)  IV Abx for Exacerbations  Nebulised DNAase Hypertonic Saline  Lung Transplant  Replace Pancreatic Enzymes  High Calorie Diet 150%  Fat Soluble Vitamins  Manage Complications DM and Liver Failure

Asthma  Affects 15-20% of Children. Commonest Respiratory Condition of childhood.  Can be life threatening.  Reversible airway obstruction associated with atopy.  Bronchial inflammation and airway hyperresponsiveness.  Sx - SOB, wheeze, cough, chest tightness.  Ix – Peak Flow, Spirometry  Inhaler Technique  Transient Early wheeze. <5yrs

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