Teaching Respiratory Diseases in Bedside Paediatrics Dr. Pushpa Raj Sharma Professor of Child Health Institute of Medicine

Why children are brought to Kanti Children’s Hospital? Fever Cough or difficulty in breathing. Diarrhoea/Vomiting Not feeding well Abdominal pain Rash

A child with cough or difficulty in breathing Triage by symptoms Convulsion/drowsy Grunting Bluish spell Persistent vomiting Inability to swallow/drooling of saliva Triage by signs Glasgow coma scale Stridor/chest in- drawing/flaring of ale nasi Cyanosis Dehydration Epiglottitis/peritonsil ar abscess/ retropharyngeal abscess

Detailed history: Present illness Entry questions Threading questions Duration of symptoms Onset of symptoms Risk factors Treatments Other system involvement Does your child can lie flat while sleeping? Which side s/he prefers to lie down? Hours, days, months. Preceding runny nose Mother smoker, biomass fuel for cooking Nebuliser Mental retardation

Detailed history: Past illness Recurrent episodes Present since birth Same precipitating factor Drugs used Operations IgA deficiency Congenital anomaly Asthma Salbutamol in asthma Tonsillectomy

Birth history Antenatal infection Prematurity Low birth weight Intubation Hypothermia Jaundice Pneumonia Immature lung Pneumonia Laryngeal stenosis Surfactant deficiency Alfpha 1 antitrypsin deficiency

Nutritional history Formula feeding Vit A deficiency Protein deficiency Adequate calorie Inadequate calorie Cows milk Too much calorie Asthma Pneumonia Recurrent infection Hyper catabolic state Hypoglycaemia Haemosiderosis Diminished chest expansion

Developmental history Delayed motor milestones. Trisomy Mental retardation Recurrent infections. IgA deficiency Aspirations

Family/social history Over crowding Similar disease Smoker Domestic smoke Carpet worker Change of place Sleeping with coal heat Recurrent infections Tuberculosis Cough Tuberculosis/asthma Asthma CO poisoning

Inspection Respiratory rate Pattern of breathing Triage signs Red eyes/runny nose Transverse creases in the nose Prominent maxilla Harrison's sulcus Atopic eczema Pneumonia Acidosis Grunting etc Viral infections Allergic rhinitis Enlarged adenoids Recurrent obstructive air way disease Asthma

Palpation Tenderness Displaced apex beat movement Cervical nodes vocal fremitus Liver Shifting trachea Trauma Pneumo/collapse Pneumonia/effusion Lymphoma Consolidation Pneumothorax/sepsi s Effusion/collapse

Auscultation Turbulent air flow through the respiratory tube causes vibration of its wall Sound generated by this vibration is transmitted through different media to the ear drum then to cortex Inspiration and expiration will have different quality Changes in the wall and conducting media changes the quality of sound

Types of respiratory sound Different names Dry sounds Vesicular Bronchial Vesicular with prolonged expiration Moist sound: Fine crepitations Coarse crepitations Plerual rub Snoring stridor Wheeze Ronchi Breath sound

Characteristic of moist sounds Asses with each respiratory cycle In respiratory tube whole inspiration and expiration In alveoli at the beginning and end of inspiration and expiration

Auscultation Snoring Stridor Wheeze Ronchi Prolonged expiration Vesicular Bronchial Palatal palsy Epiglottitis Asthma/foreign body Bronchiolitis Asthma Normal Consolidation/ collapse

Percussion Tenderness Hyper resonant Dullness Displace upper border of liver dullness Trauma/infection Pneumothorax Effusion/collapse/ consolidation Hyperinflation

Other system examination VSD Juvenile rheumatoid arthritis Gastrooesophageal reflux Hepatosplenomegaly Failure to thrive Recurrent pneumonia Pleural effusion Recurrent aspiration Malignancy Cystic fibrosis