TBL : Respiratory distress

Definition of respiratory system is the systems which allows exchange of

gaseous between carbon dioxide and oxygen where oxygen will be distributed
and unloaded to tissues for ventilation while carbon dioxide will be loaded into
plasma for oxygenation in alveolus and this need good amount of oxygen carrying
capacity.

Respiration is mainly consist of inspiration and expiration where there is

changes of thoracic volume and pressure to allow those process to be initiate.

Inspiration process occur : Contraction of external intercostal musclesmoves

ribcages outward and upwardsdiaphragm flattensIncrease the thorax
volumeLower the intrathoracic pressureAir from atmosphere can enter
lungs Inspiration occur

Expiration process occur : Relaxation of external intercostal muscles ribcages

moves inwards and downwardsdiaphragm become dome shapedReduce
thorax volume Increase intrathoracic pressure Air expel out.

Disease related to respiratory distress

URTI : Common cold, Acute pharyngitis , Acute Sinusitis , Acute Otitis Media

Pneumonia : Staphylococal pneumonia, Mycoplasma pneumonia, Viral Pneumonia,

Pertussis, Pulmonary Tuberculosis

Bronchiolitis : Acute viral bronchiolitis, Transient infant wheeze , Chronic Lung

Disease of Prematurity and Bronchiectasis

Acute laryngotracheobronchitis, acute epiglottitis, laryngomalacia

Congenital subglottic stenosis, retropharyngeal abcess, peritonsillar abcess,

diphteria

Chronic lung disease of prematurity

Inhaled foreign body

 Acute pharyngitis Acute Otitis Media Acute Sinusitis Common cold
Diseases (Middle ear infection)

Symptoms and Insidious onset, Fever, Ear ache, fever, Nasal congestion, Sneezing,stuffy nose,
signs sore throat, tonsillar In infant fussiness rhinorrhea>10 days without sore throat
exudates, tender and intense crying improvement associated with
adenopathy, cough, cough
coryza Older children hearing
loss
Pathophysiology GABHSTransmission Upper Respiratory tract Predisposed individuals with Rhinovirus infected
through saliva and infectioninflammatory URTImucosal swellings and through direct contact
nasal secretions of response & edema of occlusion of sinus ICAM-1
infected respiratory mucosa, ostiaReduction in oxygen receptorsinflammotry
personincubation nasopharynx and tensionReduce mucocilliary cytokines
period 2-5 eustachian tube defensetransudation occur in occurfluself
daysinvade accumulation off sinusMore viscous mucus and limiting
pharyngeal exudates obstruction alteration in cilia
mucosalocal of eustachian tube beatsMucostasis Bacterial
inflammatory response (isthmus)Air from colonization
occurM protein of middle ear is reabsorbed
GABHS same with creating negative
myocardium  pressureThis pressure
Rheumatic fever in pulls more virus or
children could occur bacteria to invade
middle ear part.
Investigation Throat culture Pneumatic otoscope Full blood count Throat culture
Rapid antigen test Hearing test Nasal swab

Management Penicillin V Amoxicillin Amoxicillin Acetaminophen

Augmentin Ibuprofen
Cefuroxime

Nasal
decongestantxylometazoline
drop/spray
Pneumonia :

Bronchiolitis : Viral illness affecting infant under age 2 years old

Virus invade nasopharynxspread cell to cellgoes to lower respiratory

tractIncrease mucus secretion/cell death, sloughing of bronchial ciliated
epithelial cellsdecrease in diameter of bronchiolar lumenturbulence flow
during expirationperibronchiolar lymphocytic infiltration/submucosal
edemaNarrowing respiratory tract & Air trappingLimited smooth muscle
constriction.

Investigation
Trigger 1 (20 minutes)

Salmah is 20 month old child. After seeing her in the clinic, the GP advises her
mother to take her immediately to the hospital A&E. Over the course of the
day, Salmah’s breathing has become very noisy and she appears to have
increasing difficulty in breathing. The staff in A&E can hear her stridor as soon
as her mother walks in with her.

Q1: List the questions that you would ask the parents to determine the cause of
her illness. Why do you want to ask these questions?

Did the child recently choke on something and have difficulty breathing or turn
blue?

Does the child have a sore throat, hoarseness, or a change in voice?

Can the child swallow?

Ask through the SOCRATES formula which does the symptoms appear sudden
onset, Severity , Progression, What position make it worse?.

Does this is the first time the child had experienced it?

Does the child had drooling saliva assoiated with noisy breathing?

Does the child had played with small toys like marbles or coins ?

Q2. What is stridor? Give video example. Which four (4) conditions will you
immediately consider in a toddler presenting acutely with noisy breathing as a
result of stridor?

Stridor is harsh, high pitch, musical sound produced by turbulent airflow

through partially obstructed airway.
In the physical examination, I need to count the respiratory rate, note the
heart rate, and assess the oxygen saturation for signs of impending respiratory
failure. Listen for stridor at rest when the child is calm or an increase in stridor
during crying or coughing. Note the phase of the breathing cycle that stridor is
heard (during inspiration, expiration, or both). Most cases of acute stridor are
inspiratory in nature. Listen for hoarseness, a barky cough, or a muffled voice.
Look for retractions, cyanosis, extreme anxiety or confusion, restlessness,
drooling, or a sniffing-type posture. With a stethoscope, note air exchange,
wheezing, and rales. Determine whether the stridor is acute or chronic.

Q3. What clinical features might you expect in a toddler with inhaled foreign
body partially obstructing as compared to a complete obstruction? Please
include diagram(s).

Inhaled foreign body partially Complete obstruction

obstruct
Conscious, able to speak Unconscious, Disable to speak

Q4. What investigation(s) you would perform in such condition?

Chest Xray

Q5. What is the basic management of a patient with acute stridor in the
emergency department or in your out-patient clinic? Any do & don’t that you
know? Briefly describe the steps that you will take.

Heimlich manoeuvere, Oropharyngeal airway, Tracheostomy, Intubation

Q6. Differentiate clinical features of tracheolaryngobrochitis (croups) from

acute epiglottitis
 Croup Acute Epiglottitis
Onset Over days Over hours
Cough characteristics Severe/Barking Absent/Slight
Feeding episode Yes No
Appearance Unwell Toxic/Very Ill
Drooling saliva Yes No
Stridor Harsh, Rasping Soft,whispering
Voice & Cry sounds Hoarse Muffle, Reluctant to
speak
Preceding cold Yes No
Fever <38.5 >38.5

Trigger 2 (20minute)

Dave is 20 month old boy . After seeing him in the clinic, the GP advises the
mother to take her immediately to the hospital A&E. Over the course of the
day, Dave’s breathing has become very noisy and he appears to have increasing
difficulty in breathing. The staff in A&E can hear wheeze as soon as the mother
walks in with him

Q1: What is wheezing? Give video example. Which four (4) conditions will you
immediately consider in a toddler presenting acutely with noisy breathing as a
result of wheezing?

Wheezing is a high-pitched, musical, adventitious lung sound produced by airflow

through an abnormally narrowed or compressed airway

Consider the episode of shortness of breath, chest tightness or pain ,coughing

at night, seasonally or after certain exposures, such as cold air or exercise
Q2. List the questions that you would ask the parents to determine the cause of
her illness. Why do you want to ask these questions?

Please describe the problem that caused you to come in today?

How has this condition impacted your child activities?

How often does this occur?

How long has this been occurring, mom?

Do you child said that she/he have any chest pain with breathing? If so, what is
the pain like, when does it occur, and what relieves it?

Do you have a cough? If yes, what does the cough sound like, when does it occur,
do you bring up any phlegm (sputum) when you cough, what does the phlegm look
like? Normal sputum is thin, clear to white in color, and tasteless and odorless.
Yellow-green colored sputum may indicate a bacterial infection and rust-colored
sputum is characteristic of pneumonia.

Do your child have any problems breathing at night? If so, how many pillows
does it help your child to get in a position to breathe easier?

Do your child have any allergies? If yes, how does that allergy affect your child
breathing?

Do you have a personal or family history of asthma, tuberculosis, lung cancer,

cystic fibrosis, bronchitis, emphysema, or any other lung disease?

Q3. What investigation(s) you would perform in such condition?

Full blood count, Pulse Oximetry, Chest x-ray

Q4. What is the basic management of a patient with wheezing in the emergency
department or in your out-patient clinic?

Oxygenation if SpO2<92%,B2 agonist inhalation,

Q5. Discuss on childhood asthma in detail. Describe the pathophysiology to

include bronchoconstriction, hyperresponsiveness, airway inflammation and
hypersensitivity.
Trigger 3 (10minutes)

A newborn who was delivered via EmLSCS 1 hour ago due to fetal distress and
was admitted to NICU. He was noted to have a difficulty in breathing with a
loud grunting sound. In view of this presentation, the medical officer in charge
needed to intubate him and put on mechanical ventilator.

Q1 : What is grunting? Why does grunting occur? Give video examples. List
causes of grunting in newborn and children.

Grunting is an expiratory noise made by neonates with respiratory problems. It

generally occurs throughout the expiratory phase of breathing, and represents
breath against a partially closed glottis.
Q2 : What is the relevant history that you should elicit in babies/child with
grunting?

Q3 : Discuss investigations that you would like to perform in such conditions?

Chest x-ray , Blood gas

Q4 : What is the basic management of patient with grunting ( emergency &

outpatient )?

Oxygen theraphy with good supervision by clinician, CPAP (Mechanical

ventilation)

Trigger 4 (10 minutes)

Raju is a 6 month old infant who was accidentally given extra dosage of cough
syrup. He was found limp and blue in his cot.This is his ABG upon arrival in A&E .

Please interpret the following ABG :

pH 7.22 ( normal 7.35 – 7.45 )

pCO2 85 mmHg ( normal 35 – 45 mmHg)

pO2 40 mmHg ( normal 45 – 55 mmHg)

HCO3 15 ( normal 15 – 18 )

Raju has metabolic acidosis without compensation.