respiratory disease in childhood nick connolly paediatric spr nhs tayside

Respiratory Respiratory Disease In Disease In ChildhoodChildhood

Nick ConnollyNick ConnollyPaediatric SpRPaediatric SpR

NHS TaysideNHS Tayside

Respiratory problems in Respiratory problems in childrenchildren

Neonatal respiratory problems Respiratory problems in older children

Chronic Acute

Scenario Scenario

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

Respiratory Distress Syndrome

Relative Surfactant deficiency1% all birthsPredominantly in preterm – inverse

relationship with gestation

Surfactant

PhospholipidApoproteinsSecreted at 30-32/40 Lack of surfactant results in atelectasis and

impairment of gas exchangeProduction stimulated by steroids

Incidence of RDS relative to gestational age

0

10

20

30

40

50

60

70

80

90

100

26 28 30 32 34 36 38 40Gestational Age

% with clinical RDS

Further problems

VentilatedSudden deterioration requiring increased

oxygenNo breath sounds on the right side of chest

Pneumothorax

Air in pleural spaceIncreased incidence with IPPV, CPAP and

ventilation Other risk factors – RDS (stiff lungs)Spontaneous - occurs in around 1% vaginal

deliveries, 1.5% caesarean sections

Chronic Lung Disease

Oxygen requirement beyond 36 weeks corrected gestation plus evidence of pulmonary parenchymal disease on CXR

Generally follows RDSBarotrauma, volume trauma, high inspired oxygenHealing stage associated with continued lung

growth over 2-3 years – often wheezy

ScenarioScenario

New born full-term infant with severe breathing difficulty after birth

?Dextrocardia

Diaphragmatic HerniaDiaphragmatic Hernia

Incidence:1/2400Associated pulmonary hypoplasiaCommonest- Posterolateral (Bochdalek),

left-sidedAvoid bag-mask IPPV?Respiratory supportSurgical

Older Children

Examination

Weight(length/height)..plotted!?clubbingChest shapeAuscultation

Breathing testsBreathing tests

Chronic problems

Cystic fibrosisCystic 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

Cystic Fibrosis

Autosomal recessiveCarrier incidence roughly 1 in 25 peopleMutations in the CFTR geneMultisystem disorderRespiratory infections are prominent

Differential diagnosisDifferential diagnosis

Immune deficiencyCiliary dyskinesiaAsthmaKartagener’s/ immotile cilia syndrome- rare

ScenarioScenario

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

Cystic Fibrosis TeamCystic Fibrosis Team

ClinicianSpecialist nurseClinical psychologistSocial workerPhysiotherapistDietician

A 7-year child presents to your A 7-year child presents to your clinic with a 3-month history of clinic with a 3-month history of cough worse at night or during cough worse at night or during

active playactive play

Diagnosis: ASTHMA

Asthma – Diagnosis in ChildrenSIGN 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 auscultationResponse to Rx

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

Asthma – Diagnosis in Children

ManagementManagement

Stage 1: Treat with inhaled beta-agonists when needed

Stage 2: Treat with regular inhaled steroidsStage 3A: Regular inhaled steroids + Long

acting beta agonistsStage 3B: Stage 3A + Leukotriene

antagonists

Passive Smoking

Reduces birthweight by 250g4500 pregnancy losses p.a.30% increase in Perinatal MortalityTeratogenic : airways, cleft lip/palateGlue ear Carcinogenic4 million children live with smoking

parentIncrease likelihood of asthma attack

Acute problems

Acute asthmaAcute asthma

Cough and wheeze worsening over hours or days

TreatmentTreatment

OxygenNebulised bronchodilatorOral prednisoloneIV salbutamolIV aminophyllineIV magnesiumVentilatory support

Scenario

6 week old presented with increased work of breathing and possible apnoes

URTI symptoms over last 2 days

Bronchiolitis

Viral infection – RSVUsually under 18 months oldMore severe in younger babies, ex prem,

family of smokersTachypnoea, poor feeding, irritating coughApnoea in small babiesTreatment is supportiveIncreased incidence of wheezing episodes in

the next ?10 years

Scenario 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

PneumoniaPneumonia

Neonates: GBS, E.coli, Klebsiella, Staph aureus

Infants: Strep pneumoniae, ChlamydiaSchool age: Strep pneumoniae, Staph

aureus, Gr A strep, Bordetella, Mycoplasma, Legionella

ScenarioScenario

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

Differential DiagnosisDifferential Diagnosis

Inhaled foreign bodyLaryngomalaciaEpiglottitis and bacterial tracheitisAllergyCroup

Croup

Viral laryngotracheobronchitisStridor, barking coughTreatment is oral steroid to reduce

inflammation

Scenario Scenario

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

Pulmonary TuberculosisPulmonary TuberculosisMycobacterium tuberculosisNotifiable disease1/3 of World Population!Droplet infectionPrevention(of severity): BCGDrug treatment: 2 mths- Isoniazid, Rifampicin, Pyrazinamide 4 mths- Isoniazid, Rifampicin

Common respiratory Common respiratory problems in childrenproblems in children

Infant respiratory distress syndromeCLDCongenital diaphragmatic herniaCystic fibrosis AsthmaBronchiolitisChildhood pneumoniasCroupTuberculosis

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