An approach to a child with respiratory symptoms

Dr LEAH GITHINJI

PAEDIATRICIAN PULMONOLOGIST

Common respiratory symptoms

Cough Runny nose Tachypnoea Snoring Stridor Wheeze

Chest pain Chest indrawing Haemoptysis Bluish discoloration

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. Hypoxaemia Pulmonary oedema Parenchymal inflammation Restricitve/obstructive diseases

Pathophysiology:

The most severe sign: Apnoea

Acute life threatening event:

Apnoea > 20 second or associated with pallor, cyanosis, convulsion or limpness. Prematurity Sepsis Meningitis/encephalitis Drugs Abnormal muscle tone

Aetiology:

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.

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

Differential diagnosis of chronic cough

Infants:

Children

Infections

Infectious

Chlamydia Pertussis Bronchiolitis

Pneumonia Croup Post nasal drip/sinusitis Asthma Foreign body Tropical eosiniphilia Environmental irritants

Non infectious

Non infectious

Asthma Domestic smoke pollution/passive smoke Gasro-eso. Reflux Foreign body Tracheo-eso. fistula

Psychogenic

Congenital anamolies

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

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

Noisy Breathing

Snoring Grunting Stridor Wheeze Ronchi

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 Sleeping difficulty; daytime somnolence, enuresis, growth failure, morning headache.

Treatment needed if:

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.
Blood count; Lateral neck X-ray; flexible bronchoscopy.

Investigation

Grunting

Low pitched expiratory sound. Protective phenomenon to prevent collapse of alveoli: PEEP Causes:

Respiratory distress syndrome Severe pneumonia, ARDS, severe sepsis CXR; O2 saturation, blood gas

Investigations:

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.

Causes of Wheeze/Ronchi

Bilateral

Unilateral

Asthma Bronchiolitis Mycoplasma Cystic fibrosis Alpha 1 antitrypsin deficiency Severe pneumonia

Pneumonia Foreign body Mediastinal mass Tuberculosis Bronchiectasis Vascualr ring

Chest Pain: Rarely cardiac origin in children.

Infective

Pneumonia; pleural effusion, pneumothorax.

Asthma Trauma Costochondritis Psychogenic Pericardial lesions

The severe signs: Chest Indrawing and Cyanosis

Chest in drawing:

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.

Vasomotor instability in acrocyanosis. Defective perfusion. Defective ventilation. Defective diffusion. Methhaemoglobinemia Hyperoxia test

Haemoptysis: not common

Blood from posterior naso-pharynx or hematemesis: the difference. Aetiology:

Bronchiectasis. Severe cough Pneumonia Foreign body Severe measles Haemangioma/ AV malformation