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An approach to a child with respiratory symptoms Dr. Pushpa Raj Sharma Professor of Child Health Institute of Medicine.

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Presentation on theme: "An approach to a child with respiratory symptoms Dr. Pushpa Raj Sharma Professor of Child Health Institute of Medicine."— Presentation transcript:

1 An approach to a child with respiratory symptoms Dr. Pushpa Raj Sharma Professor of Child Health Institute of Medicine

2 Common respiratory symptoms Cough Runny nose Tachypnoea Snoring Stridor Wheeze Chest pain Chest indrawing Haemoptysis Bluish discoloration

3 The most important sign: Tachypnea Cut off rate per minute  Less than 1 week up to 2 months: 60 or more  2 months up to 12 months: 50 or more  12 months up to 5 years: 40 or more. Pathophysiology:  Hypoxaemia  Pulmonary oedema  Parenchymal inflammation  Restricitve/obstructive diseases

4 The most severe sign: Apnoea Acute life threatening event:  Apnoea > 20 second or associated with pallor, cyanosis, convulsion or limpness. Aetiology:  Prematurity  Sepsis  Meningitis/encephalitis  Drugs  Abnormal muscle tone

5 Cough Commonest respiratory symptom. Physiological to remove excess secretions or foreign body. Cough receptors in the posterior pharynx and large bronchi. Vagus/ glossopharyngeal: afferent to cough centre –pons /medulla. Efferent to - larynx/ diaphragm/ chest wall/abdominal wall/pelvic Acute: lasts less than 2 weeks. Chronic: lasts more than 2 weeks.

6 Cough relating to time/ posture During or after feeding: aspiration Night: asthma/ post nasal drip Morning: bronchiectasis With exercise: asthma Absence during play: psychogenic Seasonal: allergen Cold: hyperreactivity

7 Differential diagnosis of chronic cough Infants:  Infections Chlamydia Pertussis Bronchiolitis  Non infectious Asthma Domestic smoke pollution/passive smoke Gasro-eso. Reflux Foreign body  Congenital anamolies Tracheo-eso. fistula Children  Infectious Pneumonia Croup Post nasal drip/sinusitis  Non infectious Asthma Foreign body Tropical eosiniphilia Environmental irritants  Psychogenic

8 Treatment of chronic cough Over the counter cold preparation:  no beneficial effect in children under 5 years. Post nasal drip:  Propped up position at 30 degree.  Treat accordingly for Allergic/non allergic rhinitis; Sinusitis Macrolides: if Mycoplasma / chlamydia suspected. Nasal steroids/ decongestant Bronchodilators/ steroids Specific treatment

9 Psychogenic Cough School aged children. The child is often a high achiever; family stress Fixed timing but disappears during sleep and when distracted. Diagnosis by observation and exclusion of other causes. Treatment: Counseling, Normal saline gargle

10 Noisy Breathing Snoring Grunting Stridor Wheeze Ronchi

11 Snoring Inspiratory harsh sound irregularly Associated with: large tonsils and adenoids; micrognathia, macroglossia, palatal palsy, pharyngeal hypotonia, obesity Diagnostic test:  Sleep study, flexible bronchoscopy, lateral x-ray neck Treatment needed if:  Sleeping difficulty; daytime somnolence, enuresis, growth failure, morning headache.

12 Stridor Inspiratory harsh sound continuously. Can occur during expiration (intrathoracic) or both phase of respiration. Asses the severity  Drooling of saliva, respiratory distress, unable to swallow, cyanosis Common causes:  Infective: epiglottitis, laryngotracheobronchitis, tracheitis, retropharyngeal abscess (rare)  Malignancy: tumor compression, papilloma  Allergic: angioneurotic oedema.  Congenital: laryngomalacia, laryngeal web, vascular ring,  Aspiration: foreign body.  Neuronal: paralysis of vocal cord. Investigation  Blood count; Lateral neck X-ray; flexible bronchoscopy.

13 Grunting Low pitched expiratory sound. Protective phenomenon to prevent collapse of alveoli: PEEP Causes:  Respiratory distress syndrome  Severe pneumonia, ARDS, severe sepsis Investigations:  CXR; O2 saturation, blood gas

14 A child who wheezes: All wheezes are not Asthma Cough could be the only symptom. Triggering factor Worse at night History of repeated problem. Symptomatic improvement with bronchodilator. Gastro-esophageal reflux: Prokinetic.

15 Causes of Wheeze/Ronchi Bilateral  Asthma  Bronchiolitis  Mycoplasma  Cystic fibrosis  Alpha 1 antitrypsin deficiency  Severe pneumonia Unilateral  Pneumonia  Foreign body  Mediastinal mass  Tuberculosis  Bronchiectasis  Vascualr ring

16 Chest Pain: Rarely cardiac origin in children. Infective  Pneumonia; pleural effusion, pneumothorax.  Born Holm disease Asthma Trauma Costochondritis Psychogenic Pericardial lesions

17 The severe signs: Chest Indrawing and Cyanosis Chest in drawing:  Increased airway resistance.  Contraction of diaphragm and pulling of ribs inside.  Negative pressure inside  Breathing in and lower chest wall goes in.  Supra sternal, inter costal recession. Cyanosis:  Vasomotor instability in acrocyanosis.  Defective perfusion.  Defective ventilation.  Defective diffusion.  Methhaemoglobinemia  Hyperoxia test

18 Haemoptysis: not common Blood from posterior naso-pharynx or hematemesis: the difference. Aetiology:  Bronchiectasis.  Severe cough  Pneumonia  Paragonimiasis  Foreign body  Severe measles  Haemangioma/ AV malformation

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