Pediatrics Respiratory System

‫‪2017/2018‬‬
‫‪Pediatrics Respiratory‬‬
‫‪disorders‬‬
‫‪By Dr ali bel kheir‬‬
‫أعرض عن الجاهل السفيه‪-‬فكل ماقال فهو فيه‬

‫ماضر بحر الفرات يوما‪-‬ان خاض بعض الكالب فيه‬
‫)االمام الشافعي(‬
subjects paper Important in
Important to know 2 Paper exam
stridor 3 Paper exam-clinic
croup 4 Paper exam- clinic
Acute epiglottitis 6 Paper exam emergency
Chronic stridor 7 Paper exam
Respiratory infection 8 Paper exam
Common cold (coryza) 9 Paper exam
Acute tonsillitis 9 Paper exam
Acute otitis Media 10 Paper exam
Pediatric Sinusitis 11 Paper exam
Pneumonia 12 Clinic+paper exam (VIP)
Lower air way narrowing 19 Paper exam- clinic
Acute bronchiolitis 19 Paper exam- clinic
Foreign body aspiration 22 Paper exam-clinic
Pulmonary Function Testing in Children 23 Paper exam
Bronchial asthma 24 Paper exam-clinic
Cystic fibrosis 31 Paper exam-clinic-
Pleural effusion 35 Paper exam
Empyema 37 Paper exam
Pneumothorax 38 Paper exam
Tuberculosis 39 Paper exam
Adenoids 40 Paper exam
D-D 40 Paper exam-clinic
1 Visit us on https://www.facebook.com/groups/easypediatrics >Dr ali bel kheir<

Important to know
Obligate nasal breathing:
 Human infants (up to 6 mts)are prefer breathing through their nose rather
than mouth
Periodic Breathing:
 Occurs when the breath pauses for up to 10 seconds at a time.
 it's not apnea and occur in first 6 mts
Clinical signs of respiratory distress

1- Mild: Tachypnea & working alan nasi
2- Moderate: + Intercostal & subcostal retractions.
3- Severe: + Grunting.
4- Advanced: + Central cyanosis, disturbed consciousness
 Tachypnea (WHO):
 Below 2 mts60 C/min
 From 2 mts up to 1 year50 C/min
 Above 1 year40 C/min
 Retraction-recession- in drawing:
 Caused by  negativity of interpleural pressure
 Can be subcostal-intercostal-sternal –suprasternal
 In URTNsuprasternal first
 In LRTNsubcostal first
 Grunting:
 abnormal,short,hoarse sounds in expiration
 The grunt occurs because the glottis briefly stops the flow of air
Raised positive end-expiratory pressure

Respiratory tract problems
 URT narrowingstridor
 LRT narrowing wheeze
………………………………………………………………………………………………………………………………………………………………………………………………..
URT narrowing and obstruction:

Stridor:
 Audible high-pitched breath sound due URTN
 its inspiratory or biphasic
Acute stridor Chronic stridor
1. Croup (most common) 1. Laryngomalacia (most common)
2. Epiglottitis 2. Laryngeal web
3. F.b.i 3. vocal cord paralysis
4. Bacterial trachitis 4. Laryngeal hemangiomas
5. angioneuratic edema 5. Vascular ring
6. Hypocalcaemia 6. Mediastinal mass
7. Others: 7. Thyroglossal cyst
• Retropharyngeal abscess 8. goiter
• Peritonsillar abscess 9. Lymphadenopathy :ex:TB
• Allergic reaction or anaphylaxis
• Infection (measles- diphtheria)
Acute stridor
Retropharyngeal abscess Peritonsillar abscess Bacterial Tracheitis
Children younger than 6 Adolescents and caused by
years preadolescents Staphylococcus aureus
1. high fevers 1. Severe throat pain 1. high fever-toxic
2. difficulty swallowing trismus 2. rapidly progressive
refusal to feed 2. trouble swallowing or airways
3. sore throat speaking 3. Obstruction
4. hyperextension of neck
5. respiratory distress
ENT ENT Treatment :
IV antibiotics + ETT

laryngotracheobronchitis= Croup
 acute viral infection of the upper airway
 It’s the most common cause of acute stridor in children
Causes:
1. Para influenza virus type 1,2,3(most common cause)
2. adeno Virus
3. RsV
4. Measles
5. Influenza
6. human meta pneumovirus
Age, season-sex:
 6mts 6yrs (peak 2yrs old)
 Common in autumn
 Slightly more common in male
Clinical pictures:
Gradual onset More severe cases:

1. Barking cough
Started with symptoms 1. RD
2. Hoarseness of voice
Of URTI for 1-2 days 2. Cyanosis
3. Strider
1. Running nose 3. Restlessness
4. Symptoms Worse at
2. Fever 4. Inspi+expira
Night
3. Cough stridor=continuous
Spasmodic croup:
 recurrent sudden episodes of stridor mainly at night with/without viral
infection allergic in origin (mainly)
Diagnosis:
 Done clinically by history – examination
 In severe cases: CI=don’t:  Until you ensure secure air way
 Don’t examine throat by tongue depressor or spatula
 Don’t put patient in flat position
 Don’t do x-ray

Investigation may be done:(limited value)
1. Anteroposterior neck x-ray steeple sign
2. Leukocytosis is uncommon
3. PCR or fluorescent antibodiesparainfuenza viruses
Management:
 Most of cases are treated at home
 Hospitalization if stridor at rest
 Try to keep baby calm to minimize forceful inspiration
Mild cases Moderate cases Sever cases

1. No RD s/s 1.Mild to moderate of 1. Sever RD
RD 2. Cyanosis
2.stridor and chest 3. Restlessness
recession disappear at 4. Toxic appearance
rest 5. Stridor at rest
Mild cases Moderate cases Sever cases
Treated at home Treated at home with Admitted to hospital
hospital observation
Inhalation of corticosteroid: 1.Nebulized epinephrine
warm moist Air 1. dexamethasone (adrenaline)
(hot shower) ( oral or IM) transient improvement 
2. budesonide rebound phenomena
inhalation=pulmicort 2.rare some pts need
neb require tracheal intubation
Complication:
 Viral pneumonia (1-2%)
Prognosis:
 Good (recover within 2-5 days)
Prevention:
 No vaccination for Para influenza virus

Acute epiglottitis “Emergency”
 its (Supraglottic) Infection of the epiglottisURT obstructiondeath
Causative organism:
1. homophiles influenzas (B) most common cause
2. Rarely by staph or pneumococci or streptococci.
Clinical picture:
 Common in age 2-7 years but can affect all age group
1. Toxic child with high fever
2. Drooling of saliva (due to severe dysphagia)
3. The child is severely exhausted
4. Voice is muffled.
5. Stridor is mild.
6. Little or no cough
7. The child prefer upright posture Tripod position
Any Attempts to lie child down or examine throat with spatula or perform
lateral X-ray must not be under taken as they can precipitate total airway
obstruction.
So if you suspect epiglottitis urgent hospital admissions is required.
Investigation:
1. CBChigh WBC
2. Blood cultureInfluenza B
3. Lateral neck x-raythumb sign

Management:
Emergency ICU A-B-C
1-(A) Artificial airway (secure air way) under GAETT
(or less often tracheostomy which can be lifesaving)
 Laryngoscope show large cherry red swollen epiglottis
2- (B) O2 inhalation.
3- (C) IV fluids + blood culture+Antibiotics: IV 3th generation cephalosporin
Corticosteroid, adrenalin its not effective
Prognosis and prevention:
 Most of cases recover completely within 2–3 days but disease with high
mortality.
 Incidence declined in developed countries due to Hi B vaccination
But not eradicated (introduced in Libya 2007)
 Chemo prophylactic baby below 48m who has not complete homophiles
influenzas vaccine, so give Rifampicin 20 mg/kg/for 4 days
………………………………………………………………………………………………………………………
Chronic stridor
Laryngomalacia Laryngeal web Subglottic
stenosis
def congenital Collapse of the congenital mucus Narrowing of
supraglottic structures membrane between trachea below the
during inspiration the vocal cords vocal cords
C/P Stridor beginning at birth (congenital) Can be congenital or
acquired (ETT)
C/P decrease after age of 1year Stridor
until disappear at 18-24 mts continuous=inspirat
stridor: ory and expiratory
↑ with crying-supine
position-URTI
↓ with prone position
diagnosis flexible laryngoscopy bronchoscopy
treatment self-limiting condition observation to Mild=Conservative
In severe cases surgery +\- sever= surgery +\-
Tracheostomy or surgery Tracheostomy Tracheostomy
Vascular ring:
 Congenital defect due double aortic arch (90%)compression on trachea
and esophagus
 Stridor beginning at birth (congenital)
 Presentation: breathing or swallowing difficulties+stridor+
cyanosis +apnea+regurgitation
 diagnosis: Gastrographin+angiography
 treatment: angiography+surgery
…………………………………………………………………………………………………………………………..
Respiratory infection
 Most common infection in children
 Most common causative organism viral 80-90%
 Risk factors:
1. Low socioeconomic state
2. Large family
3. Parental smoking
4. Boys
5. Preterm
6. If associated with cystic fibrosis or other congenital anomaly in heart or lung
7. Low immune
Types:
Upper respiratory tract infection Lower respiratory tract infection
1. Common cold (coryzal) 1. Pneumonia
2. OM 2. Bronchiolitis
3. Tonsillitis
4. Sinusitis
5. Croup
6. Diphtheria
7. Acute epiglottitis
8. Bacterial tracheitis
9. whooping cough

Common cold (coryza)
 Commonest infection of childhood
 Common cause viral: Rhinovirus-Coronavirus-Rsv
 Presented with nasal discharge-nasal blockage-low grade fever
 Treatment is Symptomatic (self-limiting) don’t use anti biotics
Acute Pharyngitis- Acute tonsillitis

Causes:
1. Viral (mostly adenoviruses,enteroviruses and rhinoviruses)
2. Bacterial (mainly by group A β heamolytic streptococcus= GABHS)
Difficult to distinguish between viral and bacterial cause
Source: Illustrated Textbook of Paediatrics Fourth Edition paper 278
Clinical picture:
General Local
1. fever 1. Dysphagia
2. anorexia 2. Sore throat (red –congested)
3. headache 3. Follicular tonsilsinflamed with white yellow exudate
4. malaise 4. Enlarged tender lymph node of neck
5. Abdominal pain
Complications: Of group A β heamolytic streptococcus ‫هام جدا‬
SUPPURATIVE NONSUPPURATIVE
1. OM-Sinusitis-Mastoditis 1. Acute rheumatic fever
2. Retropharyngeal abscess 2. PSGN
3. Cervical lymphadenitis 3. Scarlet fever
4. meningitis-pneumonia-arthritis
5. Mesentric adenitis
Treatment:
A. Symptomatic for fever.
B. Specific Ex: in streptococcus infectionOral or im penicillin
C. Tonsillectomy if there:
1. Peritonsillar abscess (Quinsy)
2. Obstructive sleep apnea
3. Frequent tonsillitis.

Acute otitis Media
Definition: supportive infection of middle ear
Risk factors:
 Eustachian tube obstruction by adenoid or inflammatory edema (URTI)
 Bottle feeding
 Infant and young children Eustachian tubes short, horizontal
 Cleft lip and palate
 Down syndrome(hypotonia) affects the opening and closing of the eustachian
 Recurrent OM can be caused by allergy to food or atopy
Source: http://www.ndss.org/Resources/Health-Care/Associated-Conditions/Ear-Nose-Throat-Issues-Down-Syndrome/
Causes:
A. ViralEx: RSV and rhinovirus
B. Bacterial: pneumococci, hemophilia influenza, Moraxella catarrhally
Streptococci
Clinical picture:
 Most common age 6-15 mts
 More in boys
General local
1. Fever 1. Severe earache
2. Anorexia=refuse feeding 2. irritability
3. Headache=irritable 3. rubbing the ears in infants
4. malaise
 Otoscope examination  drum is congested (loss of the normal light
refection)bulging  perforated + discharge
Complications:
1. MastoiditisTender swelling behind the ear
2. Chronic ear infectiondraining ears for 14 days or more
3. If recurrent OM with effusion (glue ear)most common cause of
Conductive hearing lossspeech and learning difficulties
4. dural vein thrombosis and meningitis
Treatment: 80% resolved spontaneous
1. Symptomatic for pain & feverparacetamol
2. Specific = antibiotics for 10 days amoxicillin or Co-amoxiclav
3. Surgical = myringotomy & drainage rarely needed.

Pediatric Sinusitis
 Sinuses are  fully developed at 10 years.
 The maxillary and ethmoid sinuses are present at birth.
 Frontal sinusitis rare below 5 years of age.
Sinusitis can be caused by:
1. Viral illness (common) (important)
2. Allergy
3. Secondary bacterial infection
Source: http://www.entnet.org/content/pediatric-sinusitis
Symptoms:
1. a “cold” lasting more than 10 to 14 days
2. thick yellow-green nasal drainage
3. headache, usually in children age six or older
4. pain over checks↑ with Straining
5. sore throat-cough-fever
Diagnosis:
1. CT scan =confirms the diagnosis of sinusitis
2. X-ray PNS
Treatment:
Acute sinusitis:
 antibiotic therapy for 14 days  (amoxicillin or Co-amoxiclav)
Source: http://www.aafp.org/afp/2014/0415/p676.html
 Nasal decongestant sprays or saline nasal sprays may also be prescribed for
(short-term) Relief of stuffiness.
 Analgesia can be use
Chronic sinusitis: MCQ
 sinusitis for at least 12 Weeks
 The ENT may recommend medical(common) or surgical (rare)
Complication:
1. Orbital cellulitis
2. dural vein thrombosis and meningitis
3. osteomyelitis
4. exacerbation of asthma
Pneumonia
Definition:
 Inflammation of lung parenchyma and LRT associated with radiological
change
Classification:
According to source of infection:
Community acquired pneumonia Hospital acquired pneumonia
1.Bacterial: 1- Gram-negative bacteria (common )
-Streptococcal pneumonia Example:
It's the most common cause A. Pseudomonas
2- Mycobacterial :tuberculosis B. E.coli
3.Fungal : Candida C. Klebsiella
4.Protozoa : Pneumocystis carinii D. Proteus
mainly in immune compromised E. Hemophilus influenzas
5. Viral: RSV, influenza & adenovirus F. Legionella (travel history)
6- Aspiration of milk or food or oil 2- Gram-positive bacteria:
7- Allergic  Eosinophilic pneumonia A. Streptococcus pneumonia
(Loffler's syndrome) B. Staphylococcus aureus.
According to presentation:
Typical Atypical
Streptococcal pneumonia Mycoplasma pneumonia =common cause
Its the most common cause Chlamydia pneumonia , Chlamydia ,
Legionella
According to age:
neonate Infant, young child Child above 5 yrs
1. Group b β hemolytic 1.Virus (RSV) most common 1. Mycoplasma
streptococci 2.bacterial: Pneumonia
(most common) 1. Streptococcal (most common)
2. G –ve enterococci pneumonia 2. Streptococcal
(E.coli) 2. Chlamydia pneumonia
3. Staph aureus 3. chlamydia
((mycobacterium tuberculosis considered at all age))
According to anatomy (radiological) :

Lobar pneumonia bronchopneumonia interstitial Aspiration
pneumonia pneumonia
Homogenous opacity Scattered opacity in Scattered unilateral Homogenous

in one or more lobes both lung perihilar pulmonary opacity in upper
infiltration lobe of right lung
Usually bacterial Bacterial or viral Usually viral Milk or oil

Risk factors:
1. anatomical problems EX: TEF
2. chronic lung disease Ex: cystic fibrosis
3. low immunity Ex: long use of steroid-Aids
4. congenital problem Ex: GERD+CHD
5. Contaminated equipment Ex: intubation
Clinical pictures:
Symptoms:
general local
1. Fever 1. Cough (dry then--> productive-wet)
2. Malaise 2. Breathlessness
3. Poor feeding 3. Grunting
4. Vomiting- Abdominal pain
Signs:
1. RD S\S
2. examination of chest
 Inspection decreased movement
 Palpation TVF
 Percussion impaired note or (dullness)
 Auscultation air entry variable (usually diminished)
Type of breathing normal vesicular or Bronchial
Add sound  crepitation (coarse)

Investigations:
1. labaratory:
1- CBC  leukocystosis: ↑neutrophilbacterial
↑ lymphocyteviral,TB,pertusis
↑ Eosinophiliechlamydia
2- ESR  ↑
3- CRP  +
4- Cold agglutinins  IgM titer mycoplasma pneumonia
5- Immunoflorescence  to detect virus or antigens.
6- Blood C/S or tracheobronchial secretion C/sfor bacterial cause
7- ABGin sever cases
2. Radiology:
A.Chest x-ray (A.P.V)repeated after 6wks
Lobar pneumonia bronchopneumonia interstitial Aspiration
pneumonia pneumonia
 complication as abscess , pneumatocele, effusion

Ex:(staph aureus,Klebsiella ) may be preseut
B.CT scan may needed for complication

Treatment:
 Most cases are managed at home.
Indication of admission:
1. O₂ sat ↓ 93%.
2. Age below 6mts
3. Sever tachypnea.
4. Granting.
5. Interfere with feed.
6. Apnea.
7. Severe dehydration and vomiting
8. Immune compromised
9. No response to oral antibiotics
10. 10. Complication
Supportive Specific= antibiotics for bacterial
pneumonia
1. Bed rest Pneumoncoccal p= penicilline or Rociphin
2. If with RD: O₂ inhalation, IV fluid Staph.aurus= cloxacillin or vancomycine
3. Antipyretic for fever Mycoplasma p= Macrolide group:
4. physiotherapy erythromycine /6h
5. Chest tube if pleural effusion. clarithromycine /12h
6. Whhezy chestbronchodilators Azithromycine daily/once
Pneumocystic carinii= Co-trimoxazol
Chlamydia= macrolid group - 3rd generation
Cephalosporin
H. influenza=3th generation cephalosporin
Klebsiella= amikacin
Notes:
 Before result of C/S give antibiotics to pts according to age-x-ray:
 Neonate 1st line ---> ampicillin + gentamycine.
2nd line ---> ampicillin + 3rd generation cephalosporine.
 Infant Co-amoxiclav.
 5yrs amoxicillin +/- macrolides
 In case of small PEresolve spontaneous with antibiotics
Large PEaspiration
Empyema chest tube

Causes of recurrent pneumonia Complications
 Local F.B.i 1. Pleural effusion-Empyema.
 Any site(Bi): 2. Lung abscessstaph, klebsiella
1. Immune deficiency. Pneumatocele.
2. Chronic illness. 3. Septicaemia/ meningitis.
3. Immotile cilia syndrome 4. HF-Pericarditis.
4. Congenital anomaliesTEF.
5. CHD with L to R shunt.
6. CF.
WHO classification of Acute Respiratory

Tract Infections (ARI)- ARI program:

Specific types of pneumonia:
Staph aureus:
 Peak age in infancy.
 Sever condition - high fever, complication :
1. Lung abscess.
2. Empyema, Pleural effusion.
3. pneumatocele
Mycoplasma-pneumonia:
 Common in school age 5-15
 Common cause of atypical picture of pneumonia.
 Minimal physical signswalking pneumonia
Pulmonary manifestation extra-pulmonary manifestation
As general C/P of  skin erythema multiform
pneumonia Steven Johnson syndrome
 CNS meningo-encephalitis
Aseptic meningitis
Cerebral ataxia
Guillain barre syndrome
 Joint arthritis
 Heartmyocarditis/pericarditis
 Bloodauto-immune hemolytic anemia
thrombocytopenia
 GITprotein loosing enteropathy
Diagnosis:
1. CBC:usually normal
2. Chest xray: radiological worse than clinical
3. Cold agglutination and serology IGM
Treatment:
 Supportive + Specific Macrolide

Chlamydia:
 Peak age 6w-6m.
 Staccato cough.
 Eye discharge (sticky eye)
 No fever
 CBCeosinophilia
 Swap from eyeserology
Aspiration pneumonia:
 Aspiration pneumonia: inhalation of oropharyngeal or gastric content into
LRT
 Chemical pneumonia: inflammation of lung due chemicals
(Ex: gastric content)
 Usually in upper lobe of right lung
 H/O chocking may be present (milk or oil??)
Treatment of aspiration pneumonia:
 Reassurance of family/signs of RD
 Observation for vital signs
 Supportive without antibiotics
 Good hydration and oxygenation
 If 2ry bacterial infection start antibiotics
If ingested Kerosene or material contain Kerosene

 Gastric lavage is contraindicatedmay lead to chemical pneumonia
 Reassurance of family.
 Drink milk
 Observation for vital signs/signs of RD

Lower air way narrowing
 Manifested during expiration
 It will lead to wheeze=whistling musical sound due pass of air in narrow
L.R.T
1st attack Acute Recurrent Persistence
1. Bronchiolitis 1. Bronchial asthma 1. Bronchial asthma 1. Cystic Fibrosis
2. Broncho 2. Bronchiectasis
2. Acute Bronchiolitis 2. GER
pneumonia 3. Vascular ring
3. BronchoPneumonia 3. Cow milk allergy
3. F.b.i 4. F.b.i
4. GERD 4. Immune
4. congestive
H.F 5. F.b.i deficiency
6. Cystic Fibrosis 5. Cystic Fibrosis
7. Bronchiectasis
8. Chronic HF
9. Cow milk allergy
Acute bronchiolitis
Definition:
 Acute inflammation of bronchioles
 Its commonest serious respiratory infection in infancy
Etiology:
1. RSV 70-80 %
2. Parainfleunza virus
3. Mycoplasma pneumonia
Incidence:
 Agebelow 2 years
 Seasonwinter and early spring
 Sexcommon in male
Clinical pictures:
Symptoms:
1. Coryzal symptoms for few days (cough-rhinitis-nasal stiffness)
2. Followed by paroxysmal cough-wheeze-breathlessness accompanied by
3. ↓appetite(refuse feeding),irritability
Signs:
 Respiratory distress+palpable liverhyper inflated chest
 Inspectionirritable baby-cyanosis
 Auscultation↓air entry bilateral
Vesicular breath with prolonged expiration
Bilateral Ronchi
Fine crepitation may be heared
Diagnosis:
Done clinicallyby history and clinical examination
A.Chest x-rayshyperinflated chest
1. tubular heart
2. Flat diaphragm
3. Ribs = anteriormore than 8
=Posteriormore than 6
4. Wide intercostal space
5. Horizontal ribs
6. Dark lung field
B.CBCnormal or mild leukocytosis
C.ABGseverity
D.Nasopharyngeal swap for PCR (serology) or immunofluorescencedetection
of virus but
E.Pulse oximetry
Management:
 If mildat home  Indication of admission:

 If severadmission 1. High risk infantpreterm baby-Immune deficiency
Chronic lung disease-CHD
2.R.R ↑60 at rest
3.Pao2 ↓ 60 in room air +- paco2 more than 45 mmhg
4.Poor feeding infant
5.Below 6 mts of age

Supportive management Specific: not for all cases
 Tachypnicgood hydration (IVF) Ribavirin (indication):
 RDgood oxygenation+nebulizer 1. Immune deficiency'
hypertonic saline 3% 2. Respiratory failure
 Febrileantipyretic 3.VLBW below 1.5 kg
 Good observation and 4.CHD with hemodynamic affected
monitorpulse oximetry 5.Chronic lung disease
Notes: Complications:
 BD has little effect 1. 2ry bacterial infection
 Corticosteroid and 2. Dehydration
antihistamine have no 3. Pneumothorax
benefit 4. Apnea
 Antibiotics has no role 5. RF-HF
6. Recurrence
7. Bronchiolitis obliterance(adenovirus
Prevention: type 3.7.21)
1. No vaccine avariable
2. RSV immunoglobulin monoclonal antibody=palivizumab monthly IM given
to child below 2 years for high risk group
3. Hand washing
4. Avoid exposure to symptomatic pts
Prognosis:
 Most of cases recover within 1-2 weeks
 Mortality around 1% due HF-dehydration-apnea
 Recurrence may occureno long life immunity

Foreign body aspiration
 An aspirated solid or semisolid object
 Can be a life-threatening emergency.
 Common in toddlers (between 6mts4years)
 Common site for F.B.I:
Below 1 year larynx
above 1 year right main bronchus (middle lobe of right lung)
 Most common foreign body aspirate are food (peanuts) and small toys
 Coins usually lodge in esophagus than in air way
 Foreign body can be Radio opaque
Radio lucent
 Foreign body also can be Irritant
Non irritant
Note: Peanuts particularly problem because it’s very irritant
pro-inflammatory
Clinical pictures:
 History : of sudden Choking, cough, wheeze, dyspnea or history of Foreign
Body aspiration (not mandatory)
 Examination: unilateral signs  Mediastinum deviation.

  Air entry / or absent.
 wheeze
Investigation:
1.Diagnosis can be made by  rigid bronchoscopy (diagnostic, therapeutic)
http://emedicine.medscape.com/article/298940-treatment
2.xray (inspiratory and expiratory)May show hyper inflated or collapsed lung
Management:
1. without respiratory distressbronchoscopy extraction
2. with respiratory distress:

1th aid for chocking infant younger 1th aid for chocking child older than
than 1 year of age than 1 year of age
•Heimlich maneuver is CI •If conscious=Heimlich maneuver
•Hold infant in prone position •If non conscious=abdominal thrust in
with head down lying down
•Give 5 interscapular
back blow using heel of hand
Complication of of F.B.I:
1. Aspiration pneumonia.
2. Bronchiectasis.
3. Collapsed lung.
4. Lung abscess
Pulmonary Function Testing in Children

 Most children can perform a valid spirometry study by 6 years of age
 Include:
1. flow meter: PEF simple effect method to assist severity of lung problem
2. Spirometry:
 Spirometry measures the amount of air that can be blown out and the
speed (ﬂow rate)of the air exhaled and inhaled
 Spirometry suggests if the lung function abnormality is obstructive,
restrictive or mixed
Obstructive disease=decreased FEV1/FVC ratio
Restrictive disease= normal ratio.
3. Lung volumes (LV)
 measure the volume of all air-containing spaces in the thorax
 (TV)=the volume of gas inhaled and exhaled with each breath
 (VC)=the maximum volume can be exhaled after a maximal inspiration
 (TLC)=the total amount of gas after a maximal inspiration
 (RV)=the amount of gas left in the lungs after maximal exhalation
4. Diﬀusion capacity for carbon monoxide (DLCO)
 provides information about the rate at which oxygen is transferred from
the lungs to the pulmonary circulation
5. ABG\oxymetry
Bronchial asthma
Definition:
 Chronic inflammatory disease of lung airway  hyper reactivity of airways
to various stimuli.
Can be:
1. Childhood= atopic= early= extrinsic.
2. Adulthood= non atopic= late= intrinsic.
 Asthma is the most common chronic respiratory disorder in childhood
(15-20% of children)
 Highest rates in developed countries
 Typical age below 10 yrs and above 2 years (can affect any age)
Pathophysiology:
 Hypersensivity reaction type 1
 Exposure to allergen  ↑IgE  IgE bind to mast cells.
 2th Exposure to allergen  allergen bind to IgE on mast cells  mast cell
release chemical mediators e.g. histamine bronchoconstriction, lamina
propria edema, mucosal secretion  cough, wheeze, dyspnea  with time
& uncontrolled cases  collagen deposition, hypertrophy of bronchial
muscles  persistence narrowing.
Risk factors: Atopy:
1. Genetics- Atopic child
Its genetic predisposing to be affected by
2. Early weaning
any type of allergy
3. Urban life
↑Allergic disorder in family↑% of allergy
4. Black race
in child
5. LBW
Allergic disorder as:
6. Parental smoking
Allergic Rhinitis-allergic Conjunctivitis-
Food allergy-urticaria-asthma-eczema
Triggers of asthma:
1- Respiratory viral infection (URTI) (e.g. RSV ).
2- Exercise (exercise induced asthma in 80% of pts ).
3- Inhalation of *air pollutants (dust-smoke).
*pollens/mites/animal products/ fungal spors.
*cold air.
*fumes/strong odour.
4- Drugs NSAIDs (e.g. Aspirin, indomethacin)-beat blocker bronchospasm.
5- Psychological stress  bronchospasm.
6- Ingestion of food  fish/ milk/ …..( pts have allergy to some type of food).
7- Humidity
8- Animals dogs-cats (pits)
9- GERD
Notes:
 Presence of one allergic disease ↑ the risk of another ( ex: patients of
bronchial asthma half of them will develop eczema at some stage during
disease.
 Best exercise for asthmatic pts is swimming because moist air improves the
symptoms of asthmatic pts.
 40% of infants and young children who have wheezing with viral infection
may will have asthma through childhood.
 80-85% of childhood asthma are associated with prior viral exposure.
Clinical pictures:
 Pts with asthma may be asymptomatic
 (sessional bronchial asthma).
 Cough-wheeze-breathlessness Features of asthma:
 Cough may be the only symptom 1- age usually above 2 yrs
=cough variant asthma 2- Recurrent of wheeze
 Symptoms mainly at night 3- +diurnal variant
 (due diurnal variant of cortisone) 4- respond to BD
 ± chest tightness 5- presence of trigger factors
 Irritability-restlessness-± Anxiety. 6- + H\O atopy
With Examination:
Inspection: Auscultation:
 ± hyper inflated chest  Diminished vesicular breath
 ± Barrel chest  Prolonged expiration
 ± Harrison’s sulcus Bilateral expiratory rhonchi
Palpation:
 ± Palpable wheeze.
Percussion:
 Bilateral hyper resonant.
Investigations:
1. CBC Esinophilia
2. ABGearly: hypocapnea washout of CO₂ by hyperventilation
Late: normal.
“ hyperrcapnea = severe asthma”.
3. X-ray± hyper inflated chest. Indications: of xray , ABG
4.Exercise tolerance test: 1. Pneumonia.
 PEF  exercise for 5 min PEF again 2. Sudden deterioration.
drop more than 15%  3. Pneumothorax.
exercise induced asthma. 4. Unable to maintain O₂ sat
5.Skin break test: ↑95%.
 Identify risk factors irritant substances.
6.PEF/ FEV₁ : by spirometer, flowmeter :
 To detect severity of disease.
 Improvement after BD strongly suggest asthma.
 PEF can be bedside test.
Classification of severity of acute asthmatic attack:

Mild Moderate Sever Life threatening
 Wheeze  Wheeze  Wheeze  Wheeze
only  tachypea  Retraction  Cyanosis
 tachypnea  Retraction
 tachypnea
O₂ sat O₂ sat = or↑92% O₂ sat ↓ 92% O₂ sat ↓ 92%
↑92%
Chest examination: E/O: Pt:
1.↓ Air entry. 1.Breathlessness 1.Restlessness.
2.Harsh vesicular affect speech, 2.Drowsy.
breath. feeding. 3.Silent chest.
3.Expiratory rhonchi. 2.Tachypnic 4.PEF 33%.
4.Prolonged 3.Tachycardia 5.Cyanosis.
expiration. HR=↑140 b/m.
4.Pulse paradoxicus
5.PEF=↓50%.
at home hospital ICU ICU
Classification of chronic asthma severity:
day with symptoms Night with PEFR, PEV₁
symptoms
Mild intermittent ↓3/w ↓3/w ↑80%
Asymptomatic BW
attacks
Mild persistent ↑3/w 3-4/m ↑80%
Moderate Daily ↑1/w 60-80%
persistent
Sever persistent Continual Frequent 60%
Management: Management of acute asthma:

At home= 2 puffers every 2 mins repeated until improved
(Repeated about 5 times).
At hospital= Indication of
1. Ventolin neb (salbutamol) max 3times admission:
2. ipratropium bromide (atrovent nebulizer) 1. Incomplete response to
once previous treatment
if not improved admitted 2. Pneumothorax.
inside the hospital start 3. Suspected pneumonia.
1. methyl prednisolone IV regular 4. Social reason.
2. Ventolin neb /2hrs 5. Baby hypoxic.
3. atrovent neb /4hrs 6. Breath sounds ↓↓↓
if improved=decrease rate 7. ↓ Level of conscious.
if not=add another BD EX: Evidence of dehydration
1. mg sulphate
2. adrenaline neb
3. aminophylline :
Loading dose  5mg/kg diluted with normal
saline over 20 min.
Maintain dose 0.7-1mg/kg/hr infusion pump
If not improved do chest xray to exclude
complication as
pneumonia-pneumothorax and use M.V

Management of chronic asthma:
Steps:
Below 5 yrs Above 5 yrs
Step 1 Short acting B₂ agonist. Short acting B₂ agonist.
Step 2 Low dose inhaler steroids + Short Low dose inhaler steroids +
acting B₂ agonist. Short acting B₂ agonist.
Step 3 Medium dose inhaler steroids + Medium dose inhaler steroids
Short acting B₂ agonist. + long acting B₂ agonist.
Step 4 High dose inhaler steroids + long High dose inhaler steroids +
acting B₂ agonist( inhaler )±oral long acting B₂ agonist.
steroids/aminophylline.
If pt with:
 Mild intermittent  do step 1
 Mild persistence  do step 2
 Moderate persistence do step 3
 Sever persistence do step 4
The management done by doing ( step up, step down role ), and the follow up
is every 1-3 in chronic cases.
Complications of bronchial asthma:
1. Pneumothorax.
2. Ling collapse.
3. Respiratory failure.
4. Chronic obstructive airway disease.

Bronchodilators
Short acting (4-6hr) Long acting (12hr) Theophylline ipratropium
bromide
Selective B₂ agonist Selective B₂ agonist ↑cAMP in anticholinergic
bronchial muscle. Parasympatholytic
 salbutamol*  salmeterol*  atrovent
 albuterol  formoterol
 terbutaline
S/E: S/E: S/E:
 hypokalemia  convulsion  dry mouth
 Tremors*  Tachycardia  sedation
 tachycardia  GIT upset  skin flushing
 tachycardia
Anti-inflammatory drugs
1. Anti-leukotriene
2. Mast cell stabilizer
 Cromolyn/Nedocromil Sodium= only in chronic
 Corticosteroid= It act by ↑ expression of B-receptors in bronchial ms.
A.inhaler=fluticasone-budesonide-beclomethazone*
B.oral=prednisolone
S/E of corticosteroids  ( not all S/E but examples ):
1) Fluid retention  ↑pressure.

2) Moon face cushing`s syndrome.
3) Acne.
4) Constipation.
5) Mood changes.
6) ↑ Infection.
7) Nausea.
8) ↑ cholesterol.

Exercise-induced Asthma in Children
 exercise-induced bronchoconstriction
 advising the patient about the types of exercise that are least likely to induce
an asthma attack, such as swimming, intermittent exercise, team games and
exercise in warm and humid air
 warm-up activities =breathing through the nose rather than the mouth
 Medication can be used such as:
1) Short-acting β2-agonists= The most common
2) Long-acting β2-agonists
3) Inhaled Corticosteroids
4) Cromolyn/Nedocromil Sodium
Status asthmaticus Emergency

Def.:
 Increasing severe asthma not responding to quick relievers within 24 hrs.
C/P:
As sever acute asthma: May be ±
1. Drowsiness or confusion.
2. Bradycardia.
3. Absent pluses paradoxus.
4. Paradoxical thoraco-abdominal movement.
5. Absent wheeze ( life threating ).
Treatment:
1. Admit to ICU.
2. Monitor vital signs, arterial blood gases.
3. X-ray to exclude complications.
4. Supportive: -O₂.
- IV fluids ( to correct dehydration ).
- Antibiotics if positive 2ry bacterial infection.
5. Specific: bronchodilators
Ipratrium bromide inhalation every 20 min for 3 doses then every 4-6 hourly
+continuous salbutamol neb then regular every 2-4 hrs
+ methyl prednisolone 1mg/kg/6h IV (with cardiac monitor)
-Other bronchodilators may be used as theophylline IV infusion.
-Mechanical ventilation used if no response

Cystic fibrosis
 Its autosomal recessive disease
 multisystem disease
 Common in Caucasians.
Causes:
 Defect in gene called (CRTR) which locate in middle of long arm of
chromosome 7 F 508 mutation found in 75% of cases.
Pathophysiology:
 CFTR gene  CFTR protein which regulates movement of chloride from
inside to outside cell  failure of this protein chloride trapped in cell
salt formation increase viscosity, dryness of secretion failure of
exocrine function
Clinical pictures:
 CF is multi systemic disorder
 Chronic obstructive air way disease infection
 Malabsorption FTT
1-In neonate:
1. Meconium ileus:
 Common presentation in neonate (10-20%)
 Pts with thick viscous meconium block ileum bowel obstruction
Presented with Failure to pass meconium in first 48 hours of life
Vomiting, constipation, FTT ,abdominal distension
Treated with: Gastrografin Enema or surgical
2. Salty taste due to  NACL in sweat (mother say that when she kiss the baby)
3. Prolonged obstructive jaundice
4. Defect of pancreatic secretion   fat soluble vitamins
  vit K bleeding
5. Pseudo barters syndrome:Hypokalemia+ Hypochloremia +Alkalosis
2-Infancy early childhood:
1. Pulmonary:
 Recurrent chest infection (%95 of pts will die from respiratory failure)
1. Pseudomonas-Staphylococcus aureus-H. influenza -Atypical mycobacteria
- Burkholderia capita
 Recurrent wheeze chest

2. Pancreas:
 Exocrine  Steatorrhea (chronic) diarrheaFTT
 Endocrine pancreatic gland Diabetes (common in old child)
3. Nose: Nasal polyp up to 30%-Sinusitis (common)
4. GIT: distal intestinal obstruction-rectal prolapse
5. Genitalia:
 Infertility in male (99%)due obstruction abnormal development of vas
deference (infertility but not sterile = normal sperm)
 Subfertility in female
6. Joint: arthritis
7. Hands,foot: clubbing
3-Late childhood:
1. Pulmonary edema
2. diabetics
3. Delayed puberty
4. liver disease (ex: Cirrhosis)
Investigation:
1. Sweat test  induce sweating by  (Pilocarpine )
((Collect sweat at least 100mg))
(+) if
Cl 60 mmol/l Na+Cl 140 mmol/l

((Repeat test 2 or 3 times to avoid. False result))
Few pts may have typical but mild symptoms and border line or even normal sweat test
2. neonatal sceeningGuthrie Testimmunoreactive trypsin (IRT)

3. DNA analysis  mutation
4. Chest x-ray  indicate pulmonary involvement
5. LFT may show obstructively restrictive pattern
6. Stool exam  malabsorptionfecal elastase  low in CFindicate
Pancreatic exocrine insufficiency

Treatment:
Multisystem disorder need Multidisciplinary approach
1. Treatment of pulmonary complication:
1. Inhaler bronchodilators Dilate air way, Easy movement of secretion
2. Physiotherapy for chest postural drainage
)‫(علم االم الطريقه وقوللها ديريها ليه بشـكل منتظم‬
(At least 2 times / day)
Young child in older

Postural drainage + chest percussion Deep breath exercises +
Physiotherapy device
3. Antibiotics as Flucloxacillin , Tobramycin  Staphylococcus aureus-

Pseudomonas
4. Mucolyticnebulizer Acetylcysteine
5. Recombinant DNAase enzyme
 Viscosity-Used one time/ day-Given by nebulizer-Very expensive
2.Nutritional therapy:
 Pancreatic E Replacement
 Vitamin. Supplement (fat soluble – AKED)
3.Treatment of diabetesinsulin
4.Lung Transplantation
Prognosis 
 prognosis of C F improved due to earlier diagnosis through screening better
mangment and new drugs
 Expected survival age increased up to 35 yeats

Bronchiectasis
Definition:  abnormal dilation of bronchi
Causes-types: 
Congenital(less common): acquired (common)
a) Primary Ciliary Dyskinesia 1. Pneumonia
(immotile cilia syndromeAR) 2. Primary TB
2. kartagners syndrome (50% of congenital 3. F.B.I
cases)= situs inversus +bronchiectasis+ 4. Bronchiolitis oblitrans
sinusitis (adenovirus)
3. Young syndrome:
bronchiectasis+sinusitis+azoospermia
4. Cystic fibrosisAR
5. Hypogammaglobulinemia
6.α 1 antitrypsin deficiency
Clinical pictures:
1. Chronic cough (copious sputum)
2. Hemoptysis
3. Recurrent pulm. infection
4. finger clubbing
5. unwell pts
6.  air entry
7. inspiratory coarse crepitations / ± Ronchi
Investigation:
1. Chest x-ray advanced cases typically (honey comb appearance)
(Nonspecific)
2. High resolution CT scandiagnostic
Signet ring appearance-honeycombing
3. bronchography for localized cases
Treatment:
 Medical (mainly)
 surgical cut the part of the hug where the dilation place

Medical treatment:
Bronchodilators chest physiotherapy rotatory antibiotics

(Postural drainage)
 Bronchodilator given 1 hour before physiotherapy-then physiotherapy done
at least 2 times /day for 5-10 min
1. rotatory antibiotics  risk of infection ex:Amoxicillin-Trimethoprim-
Augmentin-Macrolides
Surgical Rx indicated in:
1. Localized bronchiectasis
2. Massive hemoptysis
3. Inadequate pulm- infection
4. Foreign body or tumer removal
Note:
 pts of bronchiectasis should receiveyearly influenza vaccine
every 5years pneumococcal vaccine
Complication:
1. Massive hemoptysis
2. Amyloidosis
3. Cor-pulmonale
4. Visceral abscess
Prognosis:
 in congenital type (cystic fibrosis-ciliary dysfunction)
irreversiblerespiratory failure-right side HF
 in other casesgood prognosis

Pleural effusion
Definition:
 Accumulation of fluids in pleural cavity
Types of effusion:
Transudate Exudate Bloody Cheylous
Clear Turbid Bloody with Milky white
Proteins < 3gm/ld > 3gm/dl RBCs on
Cells Cells (PMNLs) microscopic
Specific gravity Specific gravity Examination
No organisms May reveal
LDH 200 IU/L organisms
LDH 200 IU/L
Causes 1.Pneumonia 1.Tumors 1. Thoracic duct
1.Renalnephrotic 2.T.B 2.Trauma obstruction or
syndrome 3.Ruptured long 2.Hemorrhagic trauma.
2.cardiac  abscess blood
CHF 4.SLE diseases.
3.liver disease 5.metastasis
6.T cell
lymphoma
Clinical picture:
 Manifestation of the cause (e.g. fever, dyspnea,..)
 RD
 Chest pain: dull aching pain, patient prefers to lie on the affected side
Chest examination:
 Inspection  unilateral bulge.
 Palpation  decreased TVF & trachea shifted to opposite side.
 Percussion  stony dullness
 Auscultation  marked diminished or abscent breath sound
Bronchial breath on top of PE

Investigations:
1. Chest x-ray:
 homogenous opacity
 Obliteration of Costophrenic angle
 + meniscus sign
 shift of the mediastinum to the opposite side
2. Thoracentesis For character of the fluid ,culture & sensitivity
3.CT
Treatment:
 Treat the cause
 Thoracocentesis with or without chest tube for:
1. Massive effusion with marked respiratory distress
2. Effusion not resolved with medical treatment
 Avoided in T.B (may lead to fistula)
 Site of aspiration  5th space mid axillary line
Treatment of chylous effusion
Diet with low fat, high protein and calories
Repeated aspiration
Total parenteral nutrition
Surgical ligation of thoracic duct
…………………………………………………………………………………………………………………
Empyema
Definition:
 Exudative pleura effusion with marked pus cells
Causes:
1. Pneumonia (staph, pneumococci, H. influenza)
2. Rupture lung abscess
3. Rupture abdominal abscess
4. Contaminated chest trauma or surgery
Clinical picture:
 same as pleural effusion with:
 High fever, toxic patient
 High incidence of complications

Complications:
1. Local spread to:
 Lung  bronchopleural fistula
 Abdomen  peritonitis
 Chest wall  empyema
 Pericardium  purulent pericarditis
2. Distant spread:
 Meningitis, arthritis, osteomyelitis, septicemia
3. in chronic cases:
 Excessive fibrosis may lead to lung collapse
Investigations:
1. Chest x-ray: as effusion but Opacity is more dense
In chronic cases, ribs crowding &may be lung collapse
2. Thoracentesis :For character of the fluid (exudates with pus cells)
3. Blood culture
Treatment:
 Closed drainage using intercostal tube with underwater seal For about 1
week
 More than one tube may be needed to drain pockets of pus
 Antibiotics according to culture and sensitivity
……………………………………………………………………………………………………………………….
Pneumothorax
Definition: presence of air in the pleural cavity
Causes:
Rupture preumatoceles - vigorous resuscitation
Rupture T.B cavity - Thoracentesis
Rupture surface alveoli - chest wall trauma
In air trapping
Clinical picture:
Symptoms:
 Asymptomatic (in small pneumothorax)  discovered accidentally
 Symptomatic  respiratory distress ( with tension pneumothorax)
Symptoms of the cause.
Chest examination:
Inspection  unilateral bulge
Palpation   TVF & trachea shifted to opposite side
Percussion  hyper resonance
Auscultation  marked diminished breath sounds
Investigations:
Chest x-ray --> jet black opacity with mediastinal shift to the opposite side
Treatment:
1. Small pneumothorax: usually resolve within 1 week
2. Symptomatic
 Closed drainage with underwater seal (specific info in instruments part)
Tuberculosis
Causative Transmission Incubation RF
organism period
mycobacterium air droplet 6 WKS 1. LSES-Poverity
tuberculosis G+ (person to person) +malnutrition
bacilli 2. Contact with infected
Acid fast-aerobic person
can affect lung- 3. Low immune
kidney-bone 4. Endemic area
 Clinical pictures:Asymptomatic or symptomatic

General Primary TB Systemic
1. Fever Mainly respiratory A.pulmonary TB
2. Night 1. PE 1. pneumonia
sweating 2. cavitation 2. effusion or caollapse
3. Fatigue 3. cervical 3. chronic cough+unexplained fever
4. Wt loss lymphadenopathy B. military TB
1. wide spread hematogenous
dissemination to multiple organs
2. hepatosplenomegaly
C.TB meningitis
1. gastrointestinal tb
2. bone and joint

Investigations:
 Tuberculin=mantoux testbecome + after 6wks of primary infection
 Chest x-rayghons focus-cavitation or diffuse fine nodular in miliray TB
 Bacteriologyacid fast in ziehl neelsen stain of gastric aspiration-sputum-CSF-
C\S
treatment:
 pulmonary TB2mts isoniazide-rifampicin-pyrazinamide then 4 mts
isoniazide and rifampicin
 Military TB3mts isoniazide-rifampicin-pyrazinamide then 12-18mts
isoniazide and rifampicin
Collected information:
Adenoids
 Greatest between 2 and 8 years of age.
 pts may presented with:
1. nasal obstruction =mouth breath
2. snoring
3. breath with opened mouth
4. repeated tonsillitis
5. adenoid face :elongated face, prominent incisors, hypoplastic maxilla,
Elevated nostrils, and a high arched palate
 treatment: adenoidectomy (in severe cases)
Cough:
 it can be dry or wet(productive)
Acute cough chronic cough
less than 2 weeks Dailey for more than 4 weeks)
A. infection as: 1.allergy (asthma-rhinitis-sinusitis)
1. Tonsillitis 2.anatomical anomaly(TEF-GERD)
2. OM 3.chronic infection(CF-TB-AIDS-recurrent
3. Croup aspiration pneumonia)
4. Acute epiglottitis 4.psychogenic
5. Pneumonia 5. aspiration pneumonia
Source: http://learn.pediatrics.ubc.ca/body-systems/respiratory-system/approach-to-a-
6. Bronchiolitis child-with-a-cough/
B.F.B.I

 Spasmodic (whooping)=(cough followed with whoop)pertussis
 Barking or croupy (cough + hoarseness of voice)croup
 Sudden onset coughs shockingF.B.I
 Nigh coughasthma-GERD
 Morning coughbronchial infection-sinusitis-allergic rhinitis
 Cough exacerbated by lying flatGERD
 Staccato coughchlamydia infection
Breathlessness=increase work of breath
 can be due
1. obstruction of air way flow as in asthma and bronchiolitis
2. disease affection lung tissue as pneumonia and TB
3. pleural disease as PE
4. heart disorders
noisy breath: due narrowing in respiratory tract
Stridor Audible high-pitched breath URTN inspiratory
sound due URTN
Snoring vibration of respiratory obstructed air inspiratory

structures during sleep movement during
sleeping breathing
mainly nasal cavity
wheeze whistling musical sound due LRTN expiratory
pass of air in narrow
Grunting abnormal,short,hoarse glottis stops the flow expiratory
sounds of air↑positive
end-expiratory
pressure
DO not forget:
 Respiratory disorder the most common illness in pediatrics (50%)
 Cause 30% of hospital admission
 Usually children have 6-8 attacks of respiratory infection /year
 Bronchial asthma is the most common chronic illness of childhood in UK
‫علي بالخير‬.‫د‬-‫بالتوفيق والنجاح للكل‬

Pediatrics Respiratory System

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‫‪2017/2018‬‬

‫أعرض عن الجاهل السفيه‪-‬فكل ماقال فهو فيه‬

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Clinical signs of respiratory distress

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URT narrowing and obstruction:

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Gradual onset More severe cases:

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Mild cases Moderate cases Sever cases

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Acute Pharyngitis- Acute tonsillitis

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Homogenous opacity Scattered opacity in Scattered unilateral Homogenous

Usually bacterial Bacterial or viral Usually viral Milk or oil

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 complication as abscess , pneumatocele, effusion

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WHO classification of Acute Respiratory

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If ingested Kerosene or material contain Kerosene

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 If mildat home  Indication of admission:

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 Examination: unilateral signs  Mediastinum deviation.

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Pulmonary Function Testing in Children

Classification of severity of acute asthmatic attack:

Management: Management of acute asthma:

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1) Fluid retention  ↑pressure.

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Status asthmaticus Emergency

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Cl 60 mmol/l Na+Cl 140 mmol/l

2. neonatal sceeningGuthrie Testimmunoreactive trypsin (IRT)

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Young child in older

3. Antibiotics as Flucloxacillin , Tobramycin  Staphylococcus aureus-

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Bronchodilators chest physiotherapy rotatory antibiotics

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 Clinical pictures:Asymptomatic or symptomatic

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Snoring vibration of respiratory obstructed air inspiratory

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