1. Respiratory Disease In Childhood
Nick Connolly
Paediatric SpR
NHS Tayside

2. Respiratory problems in children
Neonatal respiratory problems
Respiratory problems in older children
Chronic
Acute

3. Scenario
An infant born at 30 weeks gestation develops respiratory distress at age 2 hours

6. Respiratory Distress Syndrome
Relative Surfactant deficiency
1% all births
Predominantly in preterm – inverse relationship with gestation

7. Surfactant Phospholipid Apoproteins Secreted at 30-32/40
Lack of surfactant results in atelectasis and impairment of gas exchange
Production stimulated by steroids

8. Incidence of RDS relative to gestational age

9. Further problems Ventilated
Sudden deterioration requiring increased oxygen
No breath sounds on the right side of chest

11. Pneumothorax Air in pleural space
Increased incidence with IPPV, CPAP and ventilation
Other risk factors – RDS (stiff lungs)
Spontaneous - occurs in around 1% vaginal deliveries, 1.5% caesarean sections

13. Chronic Lung Disease
Oxygen requirement beyond 36 weeks corrected gestation plus evidence of pulmonary parenchymal disease on CXR
Generally follows RDS
Barotrauma, volume trauma, high inspired oxygen
Healing stage associated with continued lung growth over 2-3 years – often wheezy

14. ?Dextrocardia Scenario
New born full-term infant with severe breathing difficulty after birth
?Dextrocardia

15. 15

16. Diaphragmatic Hernia Incidence:1/2400 Associated pulmonary hypoplasia
Commonest- Posterolateral (Bochdalek), left-sided
Avoid bag-mask IPPV?
Respiratory support
Surgical

18. Older Children

19. Examination Weight(length/height)..plotted! ?clubbing Chest shape
Auscultation

20. Breathing tests

22. Chronic problems

23. Cystic fibrosis
A 1 year-old child presenting with a prolonged history of cough, loose stools and failure to thrive
A newborn infant with a raised immuno-reactive trypsin level on neonatal screening who is also found to be homozygous for the ΔF508 deletion

24. Cystic Fibrosis Autosomal recessive
Carrier incidence roughly 1 in 25 people
Mutations in the CFTR gene
Multisystem disorder
Respiratory infections are prominent

25. 25

26. Differential diagnosis
Immune deficiency
Ciliary dyskinesia
Asthma
Kartagener’s/ immotile cilia syndrome- rare

27. Scenario
NM is a 7 month old infant with cystic fibrosis who was admitted with 2 chest infections. He grew Staphylococcus aureus on his respiratory secretions

28. 28

29. Cystic Fibrosis Team Clinician Specialist nurse Clinical psychologist
Social worker
Physiotherapist
Dietician

30. A 7-year child presents to your clinic with a 3-month history of cough worse at night or during active play
Diagnosis: ASTHMA

31. Asthma – Diagnosis in Children SIGN Guideline May 2008
Clinical Features that increase probability:
One or more : wheeze, cough, chest tightness, difficulty breathing
Atopy(personal or family history)
Widespread wheeze on auscultation
Response to Rx

32. Asthma – Diagnosis in Children SIGN Guideline May 2008
High Probability – diagnosis of asthma likely (trial of Rx – further Ix if poor response) Low Probability – consider Ix & ? Referral Intermediate Probability: ?watchful waiting ?spirometry(response) ? Rx & evaluate

33. Asthma – Diagnosis in Children

34. Management Stage 1: Treat with inhaled beta-agonists when needed
Stage 2: Treat with regular inhaled steroids
Stage 3A: Regular inhaled steroids + Long acting beta agonists
Stage 3B: Stage 3A + Leukotriene antagonists

35. 35

36. Passive Smoking Reduces birthweight by 250g 4500 pregnancy losses p.a.
30% increase in Perinatal Mortality
Teratogenic : airways, cleft lip/palate
Glue ear
Carcinogenic
4 million children live with smoking parent
Increase likelihood of asthma attack

37. Acute problems

38. Cough and wheeze worsening over hours or days
Acute asthma
Cough and wheeze worsening over hours or days

39. 39

40. Treatment Oxygen Nebulised bronchodilator Oral prednisolone
IV salbutamol
IV aminophylline
IV magnesium
Ventilatory support

41. 41

42. Scenario
6 week old presented with increased work of breathing and possible apnoes
URTI symptoms over last 2 days

43. Bronchiolitis Viral infection – RSV Usually under 18 months old
More severe in younger babies, ex prem, family of smokers
Tachypnoea, poor feeding, irritating cough
Apnoea in small babies
Treatment is supportive
Increased incidence of wheezing episodes in the next ?10 years

44. 10 year old girl with cough, high
Scenario
10 year old girl with cough, high
fever and sputum production
Previously very well
Clinical examination:
Dullness on percussion
Vocal fremitus and resonance
Bronchial breathing

45. 45

46. Pneumonia Neonates: GBS, E.coli, Klebsiella, Staph aureus
Infants: Strep pneumoniae, Chlamydia
School age: Strep pneumoniae, Staph aureus, Gr A strep, Bordetella, Mycoplasma, Legionella

47. Scenario
A 2-year old child presenting with barking cough and difficulty in breathing of sudden onset

48. Differential Diagnosis
Inhaled foreign body
Laryngomalacia
Epiglottitis and bacterial tracheitis
Allergy
Croup

49. 49

50. 50

51. Croup Viral laryngotracheobronchitis Stridor, barking cough
Treatment is oral steroid to reduce inflammation

52. Scenario
9 month old infant from developing country with irritability, neck rigidity, afebrile

53. 53

54. Pulmonary Tuberculosis
Mycobacterium tuberculosis
Notifiable disease
1/3 of World Population!
Droplet infection
Prevention(of severity): BCG
Drug treatment:
2 mths- Isoniazid, Rifampicin,
Pyrazinamide
4 mths- Isoniazid, Rifampicin

55. Common respiratory problems in children
Infant respiratory distress syndrome
CLD
Congenital diaphragmatic hernia
Cystic fibrosis
Asthma
Bronchiolitis
Childhood pneumonias
Croup
Tuberculosis 55

56. FINISHED