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
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