1. APPROACH TO PEDIATRIC PULMONARY DISEASES Emily B. Gaerlan-Resurreccion, MD Pediatric Pulmonologist

2. A one year old boy is brought to the emergency room for respiratory distress. He was noted to have cough for about one week prior to consult.

3. Pediatric History Respiratory symptoms  dyspnea  cough  pain  wheezing

4. Pediatric History Respiratory symptoms  snoring  apnea  cyanosis

5. Pediatric History Respiratory symptoms chronicity timing during day or night associations with activities such as exercise or food intake

6. Pediatric History System Review  cardiac  gastrointestinal  central nervous  hematologic  immune systems

7. Pediatric History Family History similar symptoms or any chronic disease with respiratory components

9. Physical Examination Observation  Respiratory Rate  Presence of grunting  Breathing patterns  Presence of stridor

10. AgeRespiratory rate Premature40 – 70 0 – 3 months35 - 55 3 - 6 months30 – 45 6 - 12 months25 – 40 1 - 3 years20 - 30 3 - 6 years20 – 25 6 - 12 years14 – 22 >12 years12 - 18

11. Physical Examination Observation Restrictive Disease: shallow breaths Obstructive Disease: slow, deep breaths Extrathoracic: inspiratory stridor intrathoracic: expiratory stridor

12. Physical Examination Percussion limited value in small infants percussion is usually dull in restrictive lung disease and with a pleural effusion, pneumonia, and atelectasis, tympanitic in obstructive disease (asthma, pneumothorax)

13. Physical Examination Auscultation confirms the presence of inspiratory or expiratory prolongation provides information about the symmetry and quality of air movement. detects abnormal or adventitious sounds

14. Physical Examination Auscultation stridor - a predominant inspiratory monophonic noise crackles - high pitch, interrupted sounds found during inspiration and more rarely during early expiration, which denote opening of previously closed air spaces

15. Physical Examination Auscultation wheezes - musical, continuous sounds usually caused by the development of turbulent flow in narrow airways

16. Physical Examination Digital clubbing sign of chronic hypoxia but may be due to nonpulmonary etiologies Measured by phalangeal depth ratio, hyponichial angle and Schamroth’s sign

18. Diagnostic Tests Arterial blood gas the single most useful rapid test of pulmonary function overall assessment of the functional state of the respiratory system and clues about the pathogenesis of the disease

20. Diagnostic Tests TRANSILLUMINATION OF THE CHEST In infants up to at least 6 mo of age Used in the diagnosis of pneumothorax results in an unusually large halo of light in the skin surrounding the probe.

21. Diagnostic Tests CHEST ROENTGENOGRAMS posteroanterior and a lateral view (upright and in full inspiration) If pleural fluid is suspected, decubitus films are indicated.

23. Diagnostic Tests UPPER AIRWAY FILM upper airway obstruction and particularly about the condition of the retropharyngeal, supraglottic, and subglottic spaces

25. Diagnostic Tests SINUS AND NASAL FILMS uncertain use Imaging studies are not necessary to confirm the diagnosis of sinusitis in children <6 yr. CT scans are indicated if surgery is required in sinus infections

26. Diagnostic Tests CHEST CT AND MRI CT delineates the internal structure of the thorax in much greater detail MRI is an excellent procedure to delineate hilar and vascular anatomy

30. Diagnostic Tests Fluoroscopy  evaluating stridor and abnormal movement of the diaphragm or mediastinum  Aid in needle aspiration or biopsy of a peripheral lesion

31. Diagnostic Tests BARIUM SWALLOW  recurrent pneumonia  persistent cough of undetermined cause  stridor  persistent wheezing  gastroesophageal reflux

33. Diagnostic Tests BRONCHOGRAPHY  Diagnosis of suspected bronchiectasis or airway anomalies  instilling contrast material directly into the airway  CT and MRI have largely replaced bronchography

36. Diagnostic Tests PULMONARY ARTERIOGRAPHY AND AORTOGRAMS  evaluation of the pulmonary vasculature  vascular rings and suspected pulmonary sequestration  Replaced by Real-time and Doppler echocardiography and thoracic CT with contrast

38. Diagnostic Tests RADIONUCLIDE LUNG SCANS  evaluating pulmonary embolism and congenital cardiovascular and pulmonary defects  replaced by spiral reconstruction CT with contrast medium enhancement

40. Diagnostic Tests PULMONARY FUNCTION TESTING  define the type of process (obstruction, restriction)  define the degree of functional impairment  Used in following the course and treatment of disease

41. Diagnostic Tests PULMONARY FUNCTION TESTING  Used in estimating the prognosis of disease  preoperative evaluation and in confirmation of functional impairment in patients having subjective complaints but a normal physical examination

42. Diagnostic Tests PULMONARY FUNCTION TESTING  plethysmography  spirometry  diffusing capacity for carbon monoxide (DLCO)

44. Restrictive lung disease decrease total lung capacity(TLC ) decreases vital capacity

45. Obstructive lung disease increase residual volume and FRC produce gas trapping

46. MICROBIOLOGY: EXAMINATION OF LUNG SECRETIONS Nasopharyngeal or throat cultures by nasotracheal aspiration by transtracheal aspiration through the cricothyroid membrane

47. MICROBIOLOGY: EXAMINATION OF LUNG SECRETIONS by a sterile catheter inserted into the trachea either during direct laryngoscopy or through an endotracheal tube

48. MICROBIOLOGY: EXAMINATION OF LUNG SECRETIONS Sputum specimen presence of alveolar macrophages (large, mononuclear cells) is the hallmark of tracheobronchial secretions.

49. MICROBIOLOGY: EXAMINATION OF LUNG SECRETIONS Sputum specimen nasopharyngeal and tracheobronchial secretions : ciliated epithelial cells Nasopharyngeal and oral secretions : squamous epithelial cells

50. MICROBIOLOGY: EXAMINATION OF LUNG SECRETIONS Gastric aspirate suitable for culture for acid-fast bacilli During sleep, mucociliary transport continually brings tracheobronchial secretions to the pharynx, where they are swallowed

51. MICROBIOLOGY: EXAMINATION OF LUNG SECRETIONS Wright-stained smear of sputum or bronchoalveolar lavage (BAL) fluid bacterial : PMN leukocytes allergic disease : Eosinophils viral : intranuclear or cytoplasmic inclusion bodies fungal : Gram or silver stains

52. EXERCISE TESTING for detecting diffusion impairment assessment of the patient's exercise tolerance

54. SLEEP STUDIES Polysomnographic studies Diagnosis of obstructive sleep apnea or hypoventilation during sleep Diagnosis of disorders of respiratory control

56. LUNG VISUALIZATION AND LUNG SPECIMEN–BASED DIAGNOSTIC TESTS

57. LARYNGOSCOPY performed with either a rigid or a flexible instrument evaluation of stridor, problems with vocalization, and other upper airway abnormalities

59. BRONCHOSCOPY AND BRONCHEOALVEOLAR LAVAGE (BAL) Bronchoscopy :inspection of the airways BAL :used to obtain a representative specimen of fluid and secretions from the lower respiratory tract

61. Indications for diagnostic bronchoscopy and BAL recurrent or persistent pneumonia atelectasis unexplained or localized and persistent wheeze the suspected presence of a foreign body hemoptysis

62. Indications for diagnostic bronchoscopy and BAL suspected congenital anomalies mass lesions interstitial disease pneumonia in the immunocompromised host

63. Indications for therapeutic bronchoscopy and BAL bronchial obstruction by mass lesions foreign bodies or mucous plugs general bronchial toilet bronchopulmonary lavage

64. Rigid bronchoscopy ventilation is accomplished through the scope for the extraction of foreign bodies, for the removal of tissue masses, and in patients with massive hemoptysis

65. Flexible bronchoscopy ventilation around the flexible scope can be passed through endotracheal or tracheostomy tubes

66. Flexible bronchoscopy can be introduced into bronchi that come off the airway at acute angles can be safely and effectively inserted with topical anesthesia and conscious sedation

69. Complications  related to sedation  transient hypoxemia  laryngospasm  Bronchospasm  cardiac arrhythmias

70. Complications  Iatrogenic infection  bleeding  pneumothorax  pneumomediastinum

71. THORACOSCOPY  pleural cavity can be examined  thoracoscope is inserted through an intercostal space lung is partially deflated allows the operator to view the surface of the lung, the pleural surface of the mediastinum diaphragm and parietal pleura

72. THORACOSCOPY Indications:  endoscopic lung biopsy  pleural biopsy  bleb resection  pleural abrasion  ligation of vascular rings

74. THORACENTESIS  For diagnostic or therapeutic purposes  fluid is removed from the pleural space by needle

75. THORACENTESIS Complications  include infection  pneumothorax  bleeding

76. Transudates vs. Exudates Transudates result from mechanical factors influencing the rate of formation or reabsorption of pleural fluid and generally require no further diagnostic evaluation

77. Transudates vs. Exudates Exudates result from inflammation or other disease of the pleural surface and underlying lung and require a more complete diagnostic evaluation

79. PERCUTANEOUS LUNG TAP  most direct method of obtaining bacteriologic specimens from the pulmonary parenchyma  only technique other than open lung biopsy not associated with at least some risk of contamination by oral flora

80. PERCUTANEOUS LUNG TAP Major indications for a lung tap  roentgenographic infiltrates of undetermined cause  those unresponsive to therapy in immunosuppressed patients who are susceptible to unusual organisms

82. LUNG BIOPSY  only way to establish a diagnosis, especially in protracted, noninfectious disease  thoracoscopic or open surgical biopsies

84. Thank you