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

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

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: 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

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 Asthma Bronchiolitis Mycoplasma Cystic fibrosis Alpha 1 antitrypsin deficiency Severe pneumonia Unilateral Pneumonia Foreign body Mediastinal mass Tuberculosis Bronchiectasis Vascualr ring

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 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

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