1. Obstructive respiratory diseases Mária Adonyi Pediatric Clinic, University of Pécs Mária Adonyi Pediatric Clinic, University of Pécs

2. NARROWINGS IN THE NASOPHARYNX Choanal atresia Adenoid vegetation Teratomas Tumors Foreign body Choanal atresia Adenoid vegetation Teratomas Tumors Foreign body NARROWINGS IN THE PHARYNX Macroglossia Tonsillar hypertrophy Haemangioma Lymphangioma Retropharyngeal absc. Macroglossia Tonsillar hypertrophy Haemangioma Lymphangioma Retropharyngeal absc.

3. GLOTTIC NARROWINGS Vocal cord paresis Granulation tissue Papillomatosis Vocal cord paresis Granulation tissue Papillomatosis SUPRAGLOTTIC NARROWINGS Epiglottitis Congenital inspiratory stridor Cysts Epiglottitis Congenital inspiratory stridor Cysts SUBGLOTTIC NARROWINGS Congenital Acquired (post-intubation)

4. TRACHEO- BRONCHIAL NARROWINGS Congenital or acquired - Extramural – compression vascular ring, cyst, lymph node, tumor cause irreversible cartilage degeneration - Mural – cartilage weakness, tracheomalacia - Intramural foreign body, granulation tissue, scars, discharge, tumor Congenital or acquired - Extramural – compression vascular ring, cyst, lymph node, tumor cause irreversible cartilage degeneration - Mural – cartilage weakness, tracheomalacia - Intramural foreign body, granulation tissue, scars, discharge, tumor

5. DIAGNOSIS OF STRIDOR History taking Physical examination Radiological diagnosis Endoscopic procedures History taking Physical examination Radiological diagnosis Endoscopic procedures

6. RESPIRATORY INFECTIONS Common cold Acute otitis media, sinusitis Pharyngitis, tonsillitis, diphteria Whooping cough Laryngo-tracheo-bronchitis (Croup sy) Epiglottitis Acute bronchitis Bronchiolitis Pneumonia In children under the age of 5, 50% of diseases are acute respiratory infections. Common cold Acute otitis media, sinusitis Pharyngitis, tonsillitis, diphteria Whooping cough Laryngo-tracheo-bronchitis (Croup sy) Epiglottitis Acute bronchitis Bronchiolitis Pneumonia In children under the age of 5, 50% of diseases are acute respiratory infections.

7. CROUP SYNDROME acute laryngo-tracheo-bronchitis Acute viral infection characterized by : a barking cough, inspiratory stridor, hoarseness, caused by subglottic stenosis. inspiratory stridor lasting for hours usually occurs at night the child has no fever does not seem to be sick CROUP SYNDROME acute laryngo-tracheo-bronchitis Acute viral infection characterized by : a barking cough, inspiratory stridor, hoarseness, caused by subglottic stenosis. inspiratory stridor lasting for hours usually occurs at night the child has no fever does not seem to be sick

8. Etiology: Human parainfluenza virus type 1,2,3, RSV, Adenovirus, Influenza virus A and B, Enterovirus, Mycoplasma pneumoniae It predominantly occurs in the first 3 years of age. It is most prevalent in late autumn or winter at the age of 2. Etiology: Human parainfluenza virus type 1,2,3, RSV, Adenovirus, Influenza virus A and B, Enterovirus, Mycoplasma pneumoniae It predominantly occurs in the first 3 years of age. It is most prevalent in late autumn or winter at the age of 2. Differential diagnosis: - Congenital stridor, - Bacterial epiglottitis, tracheitis, diphteria - Foreign body, etc.

9. Croup severity score Croup score 0 0 1 1 2 2 Stridor none Inspiratory In- and expiratory* Retractions none Nasal flaring and suprasternal retraction Sternal, sub-, intercostal* Air entry Normal Decreased Severely decreased Cyanosis Normal Cyanosis at room temperature Cyanosis 40% O2 Alertness Normal Agitated Depressed *it can be absent if the patient is exhausted and breathing is decreased score < 5 mild score 5-6 mild/moderate (emergency care depending on symptoms) score 7-8 moderate/severe (ICU necessary) score > 8 severe (ICU) *it can be absent if the patient is exhausted and breathing is decreased score < 5 mild score 5-6 mild/moderate (emergency care depending on symptoms) score 7-8 moderate/severe (ICU necessary) score > 8 severe (ICU)

10. What is to be done? if score < 7: Calm the child. Steroid Di Adreson inj 1-2 mg/kg i.m, iv., Dexamethasone: 0.6mg/kg im. or iv., Prednisone supp. Fluticasone (Flixotide EH) inhaled steroid Cold humidified air (mist). Adequate fluid intake. Monitoring. After improvement the patient can be discharged. What is to be done? if score < 7: Calm the child. Steroid Di Adreson inj 1-2 mg/kg i.m, iv., Dexamethasone: 0.6mg/kg im. or iv., Prednisone supp. Fluticasone (Flixotide EH) inhaled steroid Cold humidified air (mist). Adequate fluid intake. Monitoring. After improvement the patient can be discharged. Nebulized epinephrine, Tonogen

11. Epiglottitis Acute life-threatening bacterial infection, which causes cellulitis and oedema of the epiglottis and plica aryepiglottica, hypopharynx, and results in a narrowing. Epiglottitis Acute life-threatening bacterial infection, which causes cellulitis and oedema of the epiglottis and plica aryepiglottica, hypopharynx, and results in a narrowing. Checking the throat might induce apnoea.

12. Etiology Haemophilus influenzae B (more than 90% - before the vaccination period) Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus pyogenes, candida Between the ages of 2 - 6, regardless of seasons Reduced by 98% since the vaccination. Etiology Haemophilus influenzae B (more than 90% - before the vaccination period) Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus pyogenes, candida Between the ages of 2 - 6, regardless of seasons Reduced by 98% since the vaccination. Differential diagnosis croup, peritonsillar abscess, retropharyngeal abscess, foreign body, laryngitis elevated Lab:elevated WBC count, high CRP

13. Therapy · Keep the child as comfortable as possible. · Oxygen supplementation, oxygen mask · Specialist consultation (anaesthesiologist, ENT specialist, pediatrician) · to perform intubation in the operating room. · Cricothyrotomy if intubation is not possible. · Medications: 3. generation cephalosporins (ceftriaxone, cefotaxime). Ampicillin (100-200 mg/kg/day) and chloramphenicol (75-100 mg/kg/day) Therapy · Keep the child as comfortable as possible. · Oxygen supplementation, oxygen mask · Specialist consultation (anaesthesiologist, ENT specialist, pediatrician) · to perform intubation in the operating room. · Cricothyrotomy if intubation is not possible. · Medications: 3. generation cephalosporins (ceftriaxone, cefotaxime). Ampicillin (100-200 mg/kg/day) and chloramphenicol (75-100 mg/kg/day)

14. Clinical characteristics differentiating laryngotracheobronchitis (LTB) from epiglottitis LTB Epiglottitis Age 6 months-3 years 2-6- yr Onset Gradual Rapid Etiology Viral Bacterial Swelling Subglottic Supraglottic Cough-voice Hoarse cough No cough Stridor Inspiratory Posture Any position Sitting (tripod) Mouth Closed: nasal flaring Open chin forward, drooling Fever Absent to high High Appearance Often not acutely ill Anxious, acutely ill

15. Bronchiolitis The most common lower respiratory infection in infany (3-6 months) The most common cause of hospitalizations < 3 months of age Risk factors: under12 weeks of age, prematurity, previous cardiorespiratory disease (mortality >30%), immune deficiency Crowded living conditions, History of atopic diseases, Cigarette smoke The most common lower respiratory infection in infany (3-6 months) The most common cause of hospitalizations < 3 months of age Risk factors: under12 weeks of age, prematurity, previous cardiorespiratory disease (mortality >30%), immune deficiency Crowded living conditions, History of atopic diseases, Cigarette smoke

16. Etiology RSV - 75%, Adenovirus ( 7, 21 type), Rhinovirus, Myxovirus, Parainfluenza, Human Metapneumovirus Mycoplasma pneumonia, Chlamydia trachomatis <12weeks The desquamative inflammation of the airways. Pathophysiology

17. Symptoms Runny nose, cough, tachypnoe, dyspnoe, wheezing, chest wall retraction, ronchi and crackles, hypoxia worsening condition due to respiratory muscle fatigue Symptoms Runny nose, cough, tachypnoe, dyspnoe, wheezing, chest wall retraction, ronchi and crackles, hypoxia worsening condition due to respiratory muscle fatigue Diagnosis Medical history taking Physical examinations X ray, laboratory examinations are not necessary routinely. Diagnosis Medical history taking Physical examinations X ray, laboratory examinations are not necessary routinely.

18. Treatment - Oxygen ( warmed, humidified ), oxygen box <90% O2 SAT - symptomatic There is no evidence for the effects of beta 2 mimeticum, steroid, aminophyllin. - Monitoring transcutan oxygen level. Hypercapnia ( mismatch of ventillation-perfusion ) above pCO2 60Hgmm - ventillation. - Breastfeeding, feeding until it is possible. Antibiotics are not recommended. - Oxygen ( warmed, humidified ), oxygen box <90% O2 SAT - symptomatic There is no evidence for the effects of beta 2 mimeticum, steroid, aminophyllin. - Monitoring transcutan oxygen level. Hypercapnia ( mismatch of ventillation-perfusion ) above pCO2 60Hgmm - ventillation. - Breastfeeding, feeding until it is possible. Antibiotics are not recommended.

19. Differential diagnosis Pneumonia Cystic fibrosis Heart failure Congenital abnormalities Pneumonia Cystic fibrosis Heart failure Congenital abnormalities

20. Obstructive bronchitis Causes: viral infections Bronchitis spastica, bronchitis asthmatica, wheezy bronchitis Causes: viral infections Bronchitis spastica, bronchitis asthmatica, wheezy bronchitis „ WHEEZING” PHENOTYPES transient early wheezers non-atopic wheezers IgE-associated wheezy/asthma „ WHEEZING” PHENOTYPES transient early wheezers non-atopic wheezers IgE-associated wheezy/asthma

21. Etiology: rhinovirus, influenza virus, Mycoplasma pneumoniae, Str.pneum., Staphylococcus, Haemophilus influenzae Differential diagnosis: Bronchial asthma Pneumonia Aspiration GERD Bronchial asthma Pneumonia Aspiration GERD Treatment: Beta-2 agonists Inhaled steroid Antibiotics if necessary Treatment: Beta-2 agonists Inhaled steroid Antibiotics if necessary Obstructive bronchitis Wheezing and cough induced by infection above the age of 1. Obstructive bronchitis Wheezing and cough induced by infection above the age of 1.

22. Chronic inflammatory disease, bronchial hyperreactivity. Recurrent wheezing attacks and cough especially during the night or early morning. Intermittent airflow obstruction. Chronic inflammatory disease, bronchial hyperreactivity. Recurrent wheezing attacks and cough especially during the night or early morning. Intermittent airflow obstruction. Bronchial asthma

23. Factors triggering asthma: allergens infections physical exercise air pollution cigarette smoke psychic factors western lifestyle etc. Factors triggering asthma: allergens infections physical exercise air pollution cigarette smoke psychic factors western lifestyle etc.

24. Asthma phenotypes Is the child completely well between symptomatic periods? Yes No Are colds the most common precipitating factor? Is exercise the most common or only precipitating factor? Does the child have clinically relevant allergic sensitization? Yes None Virus induced asthma a Exercise Induced asthma a Exercise Induced asthma a Allergen induced asthma Allergen induced asthma Unresolved asthma a,b No a Children may also be atopic b Different etiologies – including irritant exposure and as yet not evident allergies, may be included here. Bacharier LB, et al. Allergy. 2008;63(1):5–34. a Children may also be atopic b Different etiologies – including irritant exposure and as yet not evident allergies, may be included here. Bacharier LB, et al. Allergy. 2008;63(1):5–34. Identifying Clinical Phenotypes in Children >2 Years With Asthma

25. The complex interaction of genes and environmental factors modify the gene expression and the phenotype already in the early developmental stage.

26. Diagnosis:  Chest X ray - hyperinflated lungs and depressed diaphragm.  Skin Prick Test – atopy  Serum total IgE level - IgE antibody test  Lung function test - reversible decrease in FEV1- broncholysis test  Bronchial provocation tests - specific and non-specific  Treatment – Add-on therapy Diagnosis:  Chest X ray - hyperinflated lungs and depressed diaphragm.  Skin Prick Test – atopy  Serum total IgE level - IgE antibody test  Lung function test - reversible decrease in FEV1- broncholysis test  Bronchial provocation tests - specific and non-specific  Treatment – Add-on therapy

27. Treatment of acute asthma attack: Beta-2 agonist MDI: 2-4 puffs salbutamol with spacer device every 10-20 minutes for one hour. No effect: hospitalization Beta -2 agonist neubilized: 2,5-5 mg salbutamol equivalent every 20-30 minutes. Supplementary ipratropium bromid : 250ug/dose every 20-30 minutes. Maintaining appropriate oxygen level. Oral or iv. steroid 1-2mg/kg min. 3-5 days. Infusion of Beta-2 agonist. Treatment of acute asthma attack: Beta-2 agonist MDI: 2-4 puffs salbutamol with spacer device every 10-20 minutes for one hour. No effect: hospitalization Beta -2 agonist neubilized: 2,5-5 mg salbutamol equivalent every 20-30 minutes. Supplementary ipratropium bromid : 250ug/dose every 20-30 minutes. Maintaining appropriate oxygen level. Oral or iv. steroid 1-2mg/kg min. 3-5 days. Infusion of Beta-2 agonist.

28. Not all wheeze is asthma! Differential diagnosis is essential ! Other diseases which cause obstruction: croup - syndrome recurrent bronchitis, pneumonia foreign body aspiration bronchial narrowing congenital abnormalities bronchiectasia cystic fibrosis heart failure GERD Not all wheeze is asthma! Differential diagnosis is essential ! Other diseases which cause obstruction: croup - syndrome recurrent bronchitis, pneumonia foreign body aspiration bronchial narrowing congenital abnormalities bronchiectasia cystic fibrosis heart failure GERD

29. Improving neonatal care and survival resulted in new problems in infants. New type of BPD Improving neonatal care and survival resulted in new problems in infants. New type of BPD Critical period of birth.

30. Obesity - dyspnoea = asthma, asthma like symptoms Proinflamm. mediators: adiponektin, leptin Respiratory inflammation mediated by leukotrien, causes steroid resistance. Respiratory inflammation mediated by leukotrien, causes steroid resistance. Comorbidity: GERD, OSA, cardio-vascular diseases, metabolic disorders > 40 millions of obese children < 5 years of age > 40 millions of obese children < 5 years of age Obesity – increased risk of asthma