NON-INFECTIOUS

RESPIRATORY PROBLEM
 CONGENITAL DISORDERS
Choanal atresia
Laryngomalacia
 Choanal Atresia
Most common congenital anomaly of the nose
Bony (90%) or membranous (10%) septum
CHARGE syndrome - Coloboma, Heart ,
Atresia, Retarted growth, Genital and Ear
Clinically
unilateral - asymptomatic
bilateral - difficulty in breathing with
cyanosis relieved when crying
Choanal Atresia
 Choanal Atresia
Diagnosis: inability to pass a catheter through
each nostril 3-4 cm into the nasopharynx
rhinoscopy or HRCT scan

Treatment:
Supportive: oral airway, intubation or
tracheostomy; NGT
Definitive: Surgery
 LARYNGOMALACIA
Most common congenital laryngeal anomaly
Most frequent cause of stridor in infants and
children
Stridor appear at 2 weeks of life
Increase in severity up to 6 months
Diagnosis: flexible bronchoscopy
Treatment: observation - spontaneously
resolve
 LARYNGOMALACIA
clinical presentation includes onset of
stridor shortly after birth, minimal
respiratory distress, positional effects, and
marked reduction of noise when the infant
is at rest
Worse in supine position
 Foreign Bodies of the Airway
Most victims: older infants and toddlers
Children <3 yr of age account for 73% of
cases.
most serious complication: complete
obstruction of the airway
 Foreign Bodies of the Airway
Children introduce foreign objects into the
nose ( nuts, beads, erasers, crayons,
seeds)
Most common: nuts
Foreign objects irritate the nasal mucosa
swelling obstruction
 Faucial tonsils
Fishbones may get stuck
Can be removed by forceps
 Foreign Body Airway Obstruction

Most lodge in a bronchus (right bronchus

58% of cases)
the larynx or trachea in 10% of cases.
An esophageal foreign body can compress
the trachea and be mistaken for an airway
foreign body
 FBAO: Signs/Symptoms
Suspect in any previously well, afebrile
child with sudden onset of:
Respiratory distress
Choking
Coughing
Stridor
Wheezing
 Foreign Body Airway Obstruction

Diagnostic: bronchoscopy
History is the most important factor in
determining the need for bronchoscopy.
High clinical index of suspicion
RX: prompt endoscopic removal
Heimlichs maneuver
Infant: 5 back blows/5 chest thrusts
Child: Abdominal thrusts
 HYDROCARBON PNEUMONIA

Due to aspiration of kerosene

Occurs frequently among Filipino children
 HYDROCARBON PNEUMONIA

Pathology: necrosis of lung tissues

Signs and symptoms: vomiting following
ingestion
Management: NO emetics!!!
if big amount is ingested gastric
lavage
 ATELECTASIS
the incomplete expansion or complete
collapse of air-bearing tissue, results from
obstruction of air intake into the alveolar
sacs
Can be congenital or acquired (more
common)
 Acquired Atelectasis
1. bronchial obstruction
2. Abnormal alveolar surface tension
3. direct local pressure on the lungs from
contiguous organs or masses
(cardiomegaly, diaphragmatic hernia)
4. increased intrapleural pressure resulting
from effusion, pus, blood
5. neuromuscular disease : diaphragmatic
paralysis
 ATELECTASIS
Mucus plugs are a common predisposing
factor to atelectasis
Symptoms vary with the cause and extent
of the atelectasis
If small, can be asymptomatic
 Signs and symptoms
PE: limitation of chest excursion,
decreased breath sound intensity, and
coarse crackles. Breath sounds are
decreased or absent over extensive
atelectatic areas.
If the obstruction is removed, the
symptoms disappear rapidly
 Diagnosis
Based on Chest X-ray
90% of cases in children involve the upper
lobes
63% involve the right upper lobe
Complications: permanent damage of the
bronchus distal to the obstruction, fibrosis
and bronchiectasis
Treatment: directed towards the etiology
 BRONCHIECTASIS
Permanent localized dilatation of one or
more bronchi
Either congenital or acquired (more
frequent)
Usually result from necrotizing bacterial
infections (Staph, Klebsiella, B. pertussis)
Viral (adenovirus)
 BRONCHIECTASIS
Diagnosis: suspected in patients with
recurrent or persistent pneumonia
especially if the expectorate is quite
copious
- confirmed by bronchography
Treatment: antibiotic therapy and postural
drainage
 Bronchial Asthma
A disorder of the tracheobronchial tree
characterized by:
reversible airway obstruction
airway hyperreactivity
airway inflammation

A child with one affected parent has 25 % risk

of having asthma, the risk increases to 50 %
if both parents are asthmatic
Triggers of Asthma
Asthma: Pathophysiology

Bronchospasm

Bronchial Edema Increased Mucus

Production
 Clinical Manifestation of Asthma
cough
breathlessness
tachypnea
dyspnea
Hyperinflation
Wheezing - cardinal sign of asthma
 Asthma

Silent Chest
equals
Danger
 Diagnosis of Asthma
History and physical examination
Peak Expiratory Flow
Rate (PEFR) (> 20% change)
Spirometry
 Treatment
Family education
Avoidance of triggers
Bronchodilators
B2 agonist - short acting & long acting
Corticosteroids
Inhaled
oral
 Asthma: Management
Avoid
Sedatives
Depress respiratory drive
Antihistamines
dry secretions
Aspirin
High incidence of allergy
 Status Asthmaticus
Asthma attack unresponsive to -2
adrenergic agents
 Golden Rule

ALL THAT WHEEZES IS NOT ASTHMA

Pulmonary edema
Allergic reactions
Pneumonia
Foreign body aspiration
 PULMONARY TUBERCULOSIS

Caused by Mycobacterium tuberculosis

var. hominis
Mycobacteria are rod/bacillus shaped
Thick lipid cell wall (mycolic acid) that repels
standard stains (eg gram stains)
Concentrated dyes are used, then
Acid decolorization is performed
Mycobacteria resist the acid and retain color
Acid-fast
 TRANSMISSION

usually by airborne mucus droplet nuclei

person to person, generally from adult to
child and not vice-versa nor from child to
child
Transmission rarely occurs by direct
contact with an infected discharge or a
contaminated fomite
The lung is the portal of entry in >98% of
cases.
 Only Adults Transmit TB

Number of bacilli in sputum

Adult Child
108 104

Need about 105 organisms/ml for positive smear

 Factors that would ENHANCE
transmission
1. when the patient has a positive acid-fast
smear of sputum
2. an extensive upper lobe infiltrate or
cavity
3. copious production of thin sputum
4. severe and forceful cough
5. Environmental factors such as poor air
circulation
 Exposure, infection and evolution:

This exposure leads to the development of a

primary parenchymal lesion (Ghon
focus)(primary complex) in the lung with spread
to the regional lymph node(s).

The immune response (delayed hypersensitivity

and cellular immunity) develops about 46
weeks after the primary infection.
Key features suggestive of TB
The presence of three or more of the following
should strongly suggest a diagnosis of TB:
Chronic symptoms suggestive of TB
Physical signs highly of suggestive of
TB
A positive tuberculin skin test
Chest X-ray suggestive of TB.
 Primary Pulmonary TB
First experience with the disease
Incubation period: 2-10 wks
BUT if the immune system is weak , there
can be disseminated TB
In 3-6 months , it can reach the brain
(meningitis, tuberculoma, TB abscess)
In 1 year: bones
In 5-25 yrs : kidneys
 TB COMPLEX
1. primary parenchymal lesion
2. regional lymph nodes
3. lymphangitic connection between
parenchymal lesion and the lymph nodes
4. pleural effusion found on the ipsilateral
side of the lesion
 Incubation period: 2-10 weeks (will yield
positive tuberculin test)
Cell mediated immunity is responsible
 Clinical Manifestations and Diagnosis
majority develop no signs or symptoms at
any time.
Occasionally, it is marked by low-grade
fever and mild cough
 Clinical Manifestations and Diagnosis
Nonproductive cough and mild dyspnea
are the most common symptoms
Systemic complaints such as fever, night
sweats, anorexia, and decreased activity
occur less often
difficulty gaining weight or develop a true
failure-to-thrive syndrome that often does
not improve significantly until several
months of effective treatment have been
taken
 RISK for DISSEMINATION

Conditions that adversely affect cell-

mediated immunity predispose to
progression from tuberculosis infection to
disease (HIV, AIDS)
Cell-mediated immunity develops 2-12 wk
after infection (delayed type of
hypersensitivity)
 BCG VACCINE
Objective: to produce an innocuous
primary infection due to bacillus of
Calmette and Guerin (BCG) instead of
potentially dangerous primary infection
due to Mycobacterium tuberculosis, thus
activating CMI with minimal chance of
progressive disease
 BCG VACCINE

Dose: 0.05ml for NB up to 1 month

0.1ml for >1month
Route: intradermal
Efficacy: >50-80%
 BCG VACCINE
Cannot prevent people from getting
primary TB
BUT it can prevent people from getting
extrapulmonary TB ( meningitis,
diseminated TB, etc)
Tuberculin Skin Testing (Mantoux TST)

a useful diagnostic tool

After initial infection, it takes 2-10 wks
(median 3-4 wks) to develop
hypersensitivity to the PPD test.
intradermal injection of 0.1 mL purified
protein derivative
 Mantoux test
Intradermal injection of
0.1ml of PPD
T cells sensitized by prior
infection are recruited to
the skin where they
release lymphokines that
induce induration through
local vasodilatation,
edema, fibrin deposition
and recruitment of other
inflammatory cells to the
area
 TST
amount of induration is
measured in 72 hr
Tuberculin sensitivity
develops 3 wk to 3 mo
(most often in 4-8 wk)
after inhalation of
organisms.
Once positive, a PPD will
always be positive.
It will not go away with
treatment, either for LTBI
or for active disease
Interpretation of the test
Diameter of induration of 5 mm is
considered positive in:
HIV-infected children
Severely malnourished children (with clinical
evidence of marasmus or kwashiorkor)
Diameter of induration of 10 mm is
considered positive in:
Children more than 5 years or not vaccinated
with BCG.
 CHEMOPROPHYLAXIS
Primary chemoprophylaxis
Given to tuberculin negative neonates, infants
and children <5 years exposed to active TB

Secondary chemoprophylaxis
Tuberculin (+) individuals but NO clinical or
radiologic evidence of disease
 TREATMENT
6 month regimen of Isoniazid, rifampicin
and 2 months of pyrazinamide

Common side effects:

Ethambutol : optic neuritis
INH and rifampicin : Hepatotoxicity
Streptomycin: ototoxicity and vestibular
dysfunction
 2 Phases of treatment:
The intensive phase
usually covers the first 2 months of
treatment.
During this phase, most of the bacilli will
be killed.
The sputum converts from positive to
negative in more than 80 % of the new
patients within the first 2 months of
treatment.
 Phases of treatment:
The continuation phase
usually lasts 4-6 months, depending on the
treatment regimen.
intended to eliminate the remaining dormant
bacilli.
Since it is not possible to identify which
patients still have dormant bacilli, all patients
should continue their treatment until the end
of the prescribed period, to limit the number
of relapses.
 Evaluation of response to TB
(-) Anorexia 3-6 months
(-) pulmonary infiltrates 2-9 months
(-) Hilar adenopathy 2-3 years
(-) Pleural effusion 6-12 wks
 LAB
Sputum exam
traditional culture specimen in young
children is the early morning gastric acid
obtained before the child has arisen and
peristalsis has emptied the stomach of the
pooled secretions that have been
swallowed overnight.
 Progressive Primary Pulmonary
Disease
A rare but serious complication of TB in a
child occurs when the primary focus
enlarges steadily and develops a large
caseous center.
Liquefaction can cause formation of a
primary cavity associated with large
numbers of tubercle bacilli.
 Reactivation Tuberculosis
Pulmonary tuberculosis in adults
usually represents endogenous reactivation of a
site of tuberculosis infection established
previously in the body.
is rare in childhood but can occur in
adolescence.
 Reactivation Tuberculosis
Children with a healed tuberculosis infection
acquired at <2 yr of age rarely develop chronic
reactivation pulmonary disease
more common in those who acquire the initial
infection at >7 yr of age.
 Reactivation Tuberculosis
The most common pulmonary sites are the
original parenchymal focus, lymph nodes, or the
apical seedings (Simon foci) established during
the hematogenous phase of the early infection.
usually remains localized to the lungs, because
the established immune response prevents
further extrapulmonary spread.
The most common radiographic presentations
of this type of tuberculosis are extensive
infiltrates or thick-walled cavities in the apex of
the upper lobes, where oxygen tension and
blood flow are great.
 Miliary Tuberculosis
Erosion of a parenchymal focus of
tuberculosis into a blood or lymphatic
vessel can result in dissemination of the
bacilli and a miliary pattern, with small
nodules evenly distributed on the chest
radiograph
 TUBERCULOSIS
Clinical manifestations in pediatric TB may
be non-specific
TB is much more difficult to diagnose in
children
Undiagnosed or untreated TB in a child is
potentially serious,
More likely to develop severe or disseminated
disease
Knowing how to administer and read
PPDs, and to contextually interpret PPDs
and CXRs is vital
Questions?