1. דלקות ריאה חוזרות דר. דוד שוסיוב היחידה למחלות ריאה בילדים בית חולים הדסה ירושלים * חשוב ! בבחינה

2. Definition Recurrent pneumonia is defined as at least 2 pneumonia episodes in a 1-year period or at least 3 during a lifetime. * חשוב ! בבחינה

3. Recurrent Pneumonia Recurrent pneumonia constitutes a threat to the integrity and normal development of the respiratory system Every possible effort should be performed to make the correct diagnosis and treatment

4. Recurrent Pneumonia localized foreign body aspiration congenital anomalies asthma mucoid impaction diffuse Cystic Fibrosis (CF) Immunodeficiency Primary Ciliary Dyskinesia (PCD) Aspiration syndromes Vasculitis * * חשוב ! בבחינה

5. Recurrent Pneumonia localized foreign body aspiration congenital anomalies asthma mucoid impaction

6. Foreign Body Aspiration in Children Aspiration of a foreign body to the airway can endanger life immediately, or in the long term due to chronic lung infection and bronchiectasis the main goals of the treatment of foreign bodies are: ◦prevention ◦early diagnosis ◦Intervention

7. Foreign Body Aspiration in Children The diagnosis is some times very difficult as there is often no: ◦ leading history ◦typical physical examination ◦radiographic findings. *

8. Rigid Bronchoscopy

9. Foreign Body Aspiration in Children 8 months old infant developed a sudden cough while crawling on the floor. examination revealed diminished breath sounds over the right lung

11. Foreign Body Aspiration in Children A 14 months old girl choked during eating chicken soup on examination she was tachypneic and dispneic. breaths sounds were normal over both lungs chest radiograph was normal fluoroscopy was interpreted as normal

12. Due to her critical condition, rigid bronchoscopy was performed demonstrating a hollow chicken bone in the left main bronchus Foreign Body Aspiration in Children

13. Revision of the fluoroscopy film revealed the chicken bone located in the left main bronchus

14. Foreign Body Aspiration in Children A 3 year old girl was transferred from another hospital due to a severe asthma attack which did not respond to high doses of IV steroids and inhaled bronchodilators Examination revealed normal breaths sound while lying supine, however in the seating position she developed severe respiratory distress

15. Foreign Body Aspiration in Children Rigid bronchoscopy demonstrated a swollen watermelon seed sliding along the trachea

16. Inflammatory pseudo-polyp A 3 years old boy was referred to evaluate recurrent RLL pneumonia Bronchoscopy revealed a polypoid mass obstructing the Rt. main bronchus

17. Inflammatory pseudo-polyp After removing the polypoid mass, a small piece of almond was seen

18. Rigid bronchoscopies performed for suspected foreign body aspiration in children - results of 173 procedures

19. Rigid bronchoscopies performed for suspected foreign body aspiration in children *

20. Rigid bronchoscopies performed for suspected foreign body aspiration in children - history

21. Rigid bronchoscopies performed for suspected foreign body aspiration physical examination

22. Rigid bronchoscopies performed for suspected foreign body aspiration in children - Chest X ray

23. Rigid bronchoscopies performed for suspected foreign body aspiration in children -Yield of 86 fluoroscopies P=0.034

24. Indications for Bronchoscopy for Suspected Foreign Aspiration The prediction of foreign body aspiration is best achieved by: 1. history 2. physical examination 3. chest radiography *

25. Recurrent Pneumonia localized foreign body aspiration congenital anomalies asthma mucoid impaction

26. Recurrent Pneumonia Congenital anomalies distorted structure ◦sequestration ◦cystic adenomatoid malformation (CCAM) airway obstruction Stenosis Malacia external compression vascular rings, slings cysts

27. Cong Cystic Adenomatoid Malformation - CCAM

28. Pulmonary sequestration Angiography with systemic circulation

29. Bronchomalacia - LMB

32. Bronchial stenosis

33. Normal aortic arch ?Double aortic arch

34. Recurrent Pneumonia localized foreign body aspiration congenital anomalies asthma mucoid impaction

35. Asthma Right middle lobe syndrome * !

36. Recurrent Pneumonia localized foreign body aspiration congenital anomalies asthma mucoid impaction

37. Mucoid impaction : bronchial cast eosinophils dehydrated secertions Associated with : Post heart surgery * cystic fibrosis asthma allergic bronchopulmonary aspergillosis (ABPA)

38. Recurrent Pneumonia diffuse cystic fibrosis immunodeficiencies primary ciliary dyskinesia aspiration syndromes

39. Recurrent Pneumonia diffuse cystic fibrosis immunodeficiencies primary ciliary dyskinesia aspiration syndromes

40. Immunodeficiencies Agammaglobulinemia - x linked IgG subclass deficiency Complement deficiency Neutrophil abnormalities: ◦Schwachman-Diamond syndrome ◦Chronic granulomatous diseae (CGD) ◦Chediac-Higashi syndrome ◦Job’s syndrome ( תסמונת איוב ) ◦cyclic neutropenia ◦drug induced neutropenia

41. Recurrent Pneumonia diffuse cystic fibrosis immunodeficiencies primary ciliary dyskinesia (PCD) !! aspiration syndromes

42. Primary ciliary dyskinesia chronic sinusitis chronic and rec. otitis media recurrent pneumonia & bronchiectasis situs inversus (50%) male infertility (50%) Females some problems Low Nasal Nitric Oxide (NO)

45. PCD maxillary sinusitis

46. PCD maxillary sinusitis

48. Normal cilium

49. PCD

50. dysorientation of central tubules

51. Recurrent Pneumonia diffuse cystic fibrosis immunodeficiencies primary ciliary dyskinesia aspiration syndromes

53. Aspiration from above choanal stenosiscleft palate macroglossialaryngotracheal cleft micrognathiaTEF-H type vascular ring congenital anomalies

54. Tracheo-esophageal fistula

55. Aspiration from above

56. Familial Dysautonomia (FD) Riley-Day Syndrome Aspiration ◦Eating and drinking ◦GE reflux and vomiting (FD crisis) ◦Dysautonomia- Fever, high and low blood pressure etc.

57. Case Presentation,CP aspiration from above

60. Gastro-Esophageal Reflux and Aspiration one of the major causes for lung disease in infants and children diagnosis is often delayed due to: ◦unawareness ◦low sensitivity and specificity of diagnostic procedures

61. Gastro-Esophageal Reflux Disease (GERD) symptoms respiratory chronic cough wheezing recurrent pneumonia apnea stridor hoarseness gastrointestinal Vomiting irritability dysphagia anemia failure to thrive

62. Gastro-Esophageal Reflux barium swallow

63. Gastro-Esophageal Reflux 24 hr esophageal pH monitoring

64. Gastric scintigram (milk scan)

65. Recurrent Pneumonia diagnosis history physical findings ◦clubbing ◦burrel chest ◦cracels Chest x-ray Bronchoscopy HRCT Bronchography (?) Sweat Test Immunoglobulins IgE PFT with challenge Nitric Oxide (exhaled and Nasal) Arterial Blood Gas SaO2 * ! ?

66. * ! Clubbing - התאלות

67. Recurrent pneumonia LLL

68. Bronchiectasis - CT

69. Bronchiectasis - bronchography

70. Flexible bronchoscopy

71. Rigid bronchoscopy

72. PCP CMV Aspergillus fumigatus mucor

73. Cndida albicans

74. BAL – lipid laden alveolar macrophages *

75. BAL – Hemosiderin laden macrophages * ! Pulmonary hemorrhage Pulmonary Hemosiderosis Primary and seconday Hypoxia Crackles (crepitation) Pulm Infiltration in CXR (ground glass appearance) Decreased Hb during exacerbations Higher DLCO in PFT

76. Charcoal tracheal instillation

78. Recurrent pneumonia treatment Identify and treat primary cause Physiotherapy and postural drainage Hypertonic Saline Inhalation – to increase mucociliary clearance DNAase inhalation (Pulmozyme) Antibiotics (PO, IV, Inhalations) Surgery

79. תודה רבה ברוכים הבאים למשחק האמיתי