PEDIATRICS

2. Fine Crackles
Description
OUTLINE ● Auscultated during inspiration
I. ABNORMAL LUNG SOUNDS ● High-pitched, crackling sound
II. PRESCRIPTION ● Similar to a fire crackling
III. INFECTIONS OF THE UPPER RESPIRATORY TRACT
3. Pleural Friction Rub
IV. INFECTIONS CAUSING ACUTE UPPER AIRWAY
Description
OBSTRUCTION
● Auscultated during inspiration and expiration
V. INFECTIONS OF THE LOWER RESPIRATORY
● Low-pitched,harsh/grating sound
TRACT
VI. CONGENITAL ANOMALIES OF THE UPPER
AIRWAY II. PRESCRIPTION WRITING
VII. CONGENITAL ANOMALIES OF THE LOWER ● In pediatrics it is very common to give paracetamol
RESPIRATORY TRACT (Antipyretic)
VIII. TEST YOUR KNOWLEDGE
Treatment
● Paracetamol preparation:
I. ABNORMAL LUNG SOUNDS ● 100mg/ ml - drops preparation
● 120mg/5ml - in syrup (more commonly used)
● 250mg/5ml - in syrup
● When do we use drops or syrup? Drop is for <1 y/o and
syrup for >1 y/o, however for those cases that we
encountered difficulty in giving medications then we can
give the drops.
● weight x dose x preparation = ml

https://youtu.be/U8byn2NT_lo
QR Code for Abnormal Lung Sound Video
CONTINUOUS
1. High-pitched, polyphonic wheeze
Description:
● Auscultated mainly in expiration (but may present during
inspiration)
● Sounds like a high-pitched musical instrument with more
than one type of sound quality (polyphonic)
2. Low-pitched monophonic wheeze
Description:
● Auscultated mainly in expiration (but may be present at
anytime)
● Sounds like a low-pitched whistling tune or whine with one
type of sound quality (monophonic)
Computation:
● Example: The weight of the patient is 10kg, the dose is
with 10-20 mg/kg/dose (use the lowest dose, use
10mg/kg) In drops preparation, how much are we going to
give to the patient?
Solution:
● weight x dose x preparation = ml
● 10kg x 15mg/kg (for this we used 15)
● (In every 1kg of patient’s weight = 15 mg of paracetamol)
● 10kg x 15mg/kg = 150mg
● Drops prep: 1ml = 100 mg paracetamol
● X ml = 150 mg of paracetamol
● X ml = 150/100
● = 1.5 ml
● thus, in 10kg weight maximum 1.5ml drops can be given

3. Stridor
Description
● Auscultated during inspiration
● High-pitched whistling or gasping sound with harsh sound
quality
● May be seen in children with conditions such as croup or
epiglottitis, or anyone with an airway obstruction, etc. It
requires medical treatment

DISCONTINUOUS
1. Coarse Crackles Figure 1. Sample Prescription
Description:
● Auscultated during inspiration (can extend into expiration ● You have to put the name of the patient, the age, the
as well) address, the sex and the date.
● Low-pitched, wet bubbling sound ● Then put the generic name, such as paracetamol and it is
optional if you place the brand. The number here is the
number of the bottle to be brought.
PEDIATRICS (021) Respiratory Disorders Part 3
● Example 60ml paracetamol and only 1 bottle. You need
also specify the temperature, and labeled it if it is a febrile
or afebrile condition. And also write the appropriate time
when to give the medication, example you have to give
paracetamol in 1.5 drops every 4 hours for 7 days.
● Always know the weight of the patient because it is very
important especially in computing your medications.
III. INFECTIONS OF THE UPPER RESPIRATORY
TRACT
ACUTE RHINITIS/COMMON COLDS
● Inflammation of the nasal mucosa
● Occurs year round in the Philippines
● Highest incidence -June - November
● 6-10 colds per year
● If you encountered patience who take consult every month
or after 2 months due to oronasal discharge or colds you
should suspected acute rhinitis
● The common cold is an acute viral infection of the upper
respiratory tract in which the symptoms of rhinorrhea and
nasal obstruction are prominent. Systemic symptoms and
signs such as headache, myalgia, and fever are absent or
mild. The common cold is frequently referred to as
infectious rhinitis but may also include self-limited
involvement of the sinus mucosa and is more correctly
termed rhinosinusitis.
Causes
● Rhinovirus, RSV, coronavirus, coxsackie virus,
enterovirus, human metapneumovirus, influenza virus,
parainfluenza virus and adenovirus
Transmission
● Inhalation of aerosols or direct contact with
contaminated waste particles
Pathogenesis:
● RSV, influenza virus, adenovirus- trigger the
inflammatory response by direct mucosal invasion and
disruption of the nasal epithelium
● Rhinovirus-binds to ICAM-1 receptors on respiratory
epithelial cells while coronavirus grows within the
epithelium of the respiratory tract
● All of these trigger the release of cytokines and other
inflammatory mediators producing the general symptoms
of mucosal edema, increased mucus secretion and
systemic manifestations of fever, myalgia and fatigue
● incubation period- 1-3 days
● symptoms: sore throatand odynophagia(2-3 days) nasal
congestion, sensation of a lump when swallowing,
hyposmia, cough
● There is a presence of conjunctivitis - if it is cause by
adenovirus
● fatigue and severe myalgia,pain at the back of the eye-
caused by influenza infection
● fever may be absent or slight (high in infants and young
children)
● the course lasts 3-7 days although may persist for 2 weeks
● Viruses that cause the common cold are spread by three
mechanisms: direct hand contact (self-inoculation of
one’s own nasal mucosa or conjunctivae after touching a
contaminated person or object), inhalation of
small-particle aerosols that are airborne from coughing, or
deposition of large-particle aerosols that are expelled
during a sneeze and land on nasal or conjunctival mucosa
● The host immune system is responsible for most cold
symptoms, rather than direct damage to the respiratory
tract. Infected cells release cytokines, such as
interleukin-8, that attract polymorphonuclear cells into the
nasal submucosa and epithelium. HRV also increases
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vascular permeability in the nasal submucosa, releasing
albumin and bradykinin, which may contribute to
symptoms.
Physical examination of nasal cavity
● Clear to opaque white or yellow to green secretion
Figure 2. Nose of a patient showing clear secretions
● Nasal turbinates are swollen and erythematous
Figure 3. Swollen and Erythematous Nasal Turbinates
Allergic rhinitis
● presents with watery nasal discharge, itchiness and
sneezing
○ Family history of atopy
○ Eosinophils - seen in the nasal smear
○ Sinusitis - there is fever, facial pain, swelling
○ Foreign body - usually unilateral foul smelling or
bloody secretions
● The physical findings of the common cold are limited to the
upper respiratory tract. Increased nasal secretion is
usually obvious; a change in the color or consistency of
the secretions is common during the course of the illness
and does not indicate sinusitis or bacterial superinfection
but may indicate accumulation of polymorphonuclear cells.
● Examination of the nasal cavity might reveal swollen,
erythematous nasal turbinates, although this finding is
nonspecific and of limited diagnostic value. Abnormal
middle ear pressure is common during the course of a
cold. Anterior cervical lymphadenopathy or conjunctival
injection may also be noted on exam.
Diagnostic work up
● Not routinely requested except during epidemic( viral
culture, antigen detection,PCR, serology)
● A nasal smear for eosinophils (Hansel stain) may be useful
if allergic rhinitis is suspected. Self-limited radiographic
abnormalities of the paranasal sinuses are common during
an uncomplicated cold; imaging is not indicated for most
children with simple rhinitis.
Treatment
● Antipyretics, analgesics, nasal saline washes, oral/ topical
decongestants, 1st generation antihistamine with
anticholinergic properties
● Antiviral agents- oseltamivir and zanamivir given for those
worsening symptoms
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PEDIATRICS (021) Respiratory Disorders Part 3
● DO NOT GIVE antibacterial-no benefit in the treatment of
the common cold and should be avoided to minimize
possible adverse effects and the
● Development of antibiotic resistance
● Advise adequate rest, appropriate nutrition, fluid therapy
● The management of the common cold consists primarily of
supportive care and anticipatory guidance
Complication
● Otitis media, acute sinusitis, can trigger asthma
● Exacerbation, pneumonia especially if the patient is
immunocompromised
Prevention
● Influenza vaccination, proper waste disposal, good
hygiene, boost immune system
ACUTE PHARYNGITIS
● Most common cause of sore throat
● Inflammation of the pharynx and tonsils
● Caused by viruses( rhinovirus, adenovirus, coronavirus,
enterovirus and metapneumovirus)
● Bacteria (GABHS, Strep pn., Group C, Mycoplasma, C.
diphtheriae, N. gonorrhea
● Acquired through close contact with infected individuals
● Pharyngitis refers to inflammation of the pharynx, including
erythema, edema, exudates, or an enanthem (ulcers,
vesicles). Pharyngeal inflammation can be related to
environmental exposures, such as tobacco smoke, air
pollutants, and allergens; from contact with caustic
substances, hot food, and liquids; from infectious agents
Viral pharyngitis
● Sudden onset of sore throat, odynophagia, rhinorrhea,
cough, hoarseness, conjunctivitis, N/V, discrete ulcerative
lesions, tonsillopharyngeal erythema and thick yellow
secretions.
○ Epstein Barr virus - marked redness and swelling of
the throat, exudative tonsillitis, lymph gland swelling,
rash and hepatosplenomegaly
○ Herpes simplex - mucosal and palatal ulcers,
erosions and vesicles
○ Coxsackie simplex - small vesicles on soft palate,
uvula and anterior tonsillar
○ Adenovirus- fever, conjunctivitis, sorethroat, marked
pharyngeal edema, and cervical lymphnode
enlargement
○ Influenza-fever, headache, myalgia, malaise,
sorethroat, dry cough
Bacterial Pharyngitis
● GABHS (Group A Beta - Hemolytic Strep.)- fever, severe
sorethroat, headache, vomiting and abdominal pain,
pharynx and uvula are markedly erythematous and the
tonsils are enlarged and exudative, petechial hemorrhages
seen on soft palate, enlarged cervical lymp node
● diphtheria pharyngitis-barking cough and inspiratory
stridor, pseudomembrane may form around the membrane
Diagnostic test
● Not routinely done
● Throat culture- standard for strep pharyngitis
● Rapid strep antigen test- less sensitive but may provide
early identification
Treatment
Viral Pharyngitis
● no specific treatment
● warm saline gargle
● antipyretics
● anesthetic spray
● lozenges
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Streptococcal pharyngitis
● Early antibiotic treatment(Penicillin- DOC), amoxicillin,
macrolides, cephalosporin(drug resistant), clindamycin
coamoxiclav
Surgical
● Tonsillectomy-severe and recurrent pharyngitis(>7 in the
previous vear or >5 in each of the previous 2 vears)
● Streptococcal pharyngitis is relatively uncommon before
2-3 yr of age, is quite common among children 5-15 yr old,
and declines in frequency in late adolescence and
adulthood.
● The surface of the tongue can resemble a strawberry
when the papillae are inflamed and prominent (strawberry
tongue). Initially, the tongue is often coated white, and with
the swollen papillae it is called a white strawberry
tongue.
Prognosis
● Self limiting
● Good prognosis
Complications
● Bacterial otitis media, sinusitis, peritonsillar abscess,
retropharyngeal abscess
● Acute rheumatic fever, RHD, acute PSGN
○ Advise good hygiene, antimicrobial
prophylaxis(prevents recurrent GABHS and acute
rheumatic fever)
TREATMENT
● Specific therapy is unavailable for most viral pharyngitis.
However, nonspecific, symptomatic therapy can be an
important part of the overall treatment plan. An oral
antipyretic/analgesic agent (acetaminophen or ibuprofen)
can relieve fever and sore throat pain.
● Corticosteroids cannot be recommended for treatment of
most pediatric pharyngitis.
● Antibiotic therapy of bacterial pharyngitis depends on the
organism identified.
● The primary benefit and intent of antibiotic treatment is the
prevention of acute rheumatic fever (ARF); it is highly
effective when started within 9 days of onset of illness.
Antibiotic therapy does not prevent acute
poststreptococcal glomerulonephritis (APSGN).
● Antibiotic treatment should not be delayed for children with
symptomatic pharyngitis and a positive test for GAS
ACUTE SINUSITIS
● Inflammation of the paranasal sinuses
● 2nd most common complication of colds
● Mostly viral in etiology
● Bacterial cause- Strep pneumonia, non-typeable
Haemophilus influenzae, Moraxella catarrhalis
● obstruction of the sinus ostium due to inflammatory
changes in the nasal epithelium blocks sinus drainage
and impairs ciliary activity and phagocytosis result
from bacterial colonizations
● There are 2 common types of acute sinusitis: viral and
bacterial—with significant acute and chronic morbidity as
well as the potential for serious complications
● The bacterial pathogens causing acute bacterial sinusitis
in children and adolescents include Streptococcus
pneumoniae, nontypeable Haemophilus influenzae , and
Moraxella catarrhalis
Signs/symptoms
● Nasal congestion, purulent nasal discharge, hyposmia,
halitosis, postnasal drip, cough
● Headache, facial pain, swelling
● Purulent nasal discharge(>10-14 days)
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PEDIATRICS (021) Respiratory Disorders Part 3
● Children and adolescents with sinusitis can present with
nonspecific complaints, including nasal congestion,
purulent nasal discharge (unilateral or bilateral), fever, and
cough. Less-common symptoms include bad breath
(halitosis), a decreased sense of smell (hyposmia), and
periorbital edema
 hysical examination
P ● Otoscopic findings- opaque, erythematous and bulging
● Swelling and erythema of the nasal mucosa and purulent
nasal discharge
● Sinus tenderness may be detectable in adolescents and
adults. Transillumination reveals an opaque sinus that
transmits light poorly.
Diagnostics
● Sinus aspirate culture(Identify the organism) is the only
accurate method of diagnosis but is not practical for
routine use for immunocompetent patients
● Sinus plain film and Ct scan( presence of sinus
inflammation). Findings on radiographic studies (sinus
plain films, computed tomography [CT] scans), including
opacification, mucosal thickening, or presence of an
air-fluid level, are not diagnostic and are not
recommended in otherwise healthy children.
Treatment
● Amoxicillin (40mg/kg/day) for 10-14 days
● High dose amoxicillin(80-90mg/kg/day) or co-amox
● You can give topical decongestants
● antihistamine
● Saline wash
● Azithromycin and trimethoprim-sulfamethoxazole are no
longer indicated because of a high prevalence of antibiotic
resistance.
● The use of decongestants, antihistamines, mucolytics, and
intranasal corticosteroids has not been adequately studied
in children and is not recommended for the treatment of
acute uncomplicated bacterial sinusitis.
Complications
● Brain abscess and meningitis
● Osteomyelitis of the facial bones, orbital cellulitis,
periorbital cellulitis
● Other complications include osteomyelitis of the frontal
bone (Pott puffy tumor), which is characterized by edema
and swelling of the forehead, and mucoceles, which are
chronic inflammatory lesions commonly located in the
frontal sinuses that can expand, causing displacement of
the eye with resultant diplopia
ACUTE OTITIS MEDIA
● Otitis media is the most common reason that children
receive antibiotics. On the basis of culture of middle ear
fluid obtained by tympanocentesis, the predominant
causes of acute otitis media are Streptococcus
pneumoniae, H. influenzae, and M. catarrhalis. M.
catarrhalis is cultured from the middle ear fluid in 15–20%
of patients with acute otitis media
● Middle ear infection
● Higher incidence among children less than 7 years old
Pathophysiology
● The eustachian tube in children is shorter and more
horizontal and may interfere with the gravitational drainage
of nasopharyngeal secretions.
● The diameter of the tube is therefore smaller and the
mucosal wall is more compliant.
● Thus inflammation or obstruction by secretions can block
the passageway, disturb ventilation in the middle ear and
disrupt pressure equalization.
● The resultant increase in negative pressure causes
nasopharyngeal reflux and allow fluid from tissues to
accumulate in the middle ear
● Can be viral/ bacterial
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○ Viral - RSV, rhinoviruses
○ Bacterial - S. pneumoniae, non-typable H. influenzae
and M. catarrhalis, Group A strep, Staph aureus,
Gram negative organisms
Diagnosis
● Clinical history
tympanic membrane Culture of discharge- identifies the
causative organism
● Ct scan -mucosal thickening or pacification
Figure 4. Otoscopic image showing A. Normal B. TM with mild
bulging C. TM with moderate bulging D. TM with severe
bulging
Treatment
● Amoxicillin or coamoxiclav myringotomy (to relieve
pressure)
● Whether or not antibiotics are used for treatment, pain
should be assessed and, if present, treated.
● Individual episodes of AOM have traditionally been treated
with antimicrobial drugs. Concern about increasing
bacterial resistance has prompted some clinicians to
recommend withholding antimicrobial treatment in some
cases unless symptoms persist for 2 or 3 days or worsen
Complications
● Acute hearing loss, chronic ear infection
Prevention
● Immunization, avoid exposure to environmental irritants,
feeding in recumbent position is discouraged
IV.INFECTIONS CAUSING ACUTE UPPER AIRWAY
OBSTRUCTION
LARYNGOTRACHEOBRONCHITIS
●  iral croup-most common infectious cause of upper airway
V
obstruction in infants and young children
● peak incidence- 18-24 months
● transmitted via aerosol droplets or direct contact with
contaminated waste products
● Etiologic agents: Parainfluenza viruses 1 and 2, Influenza
A and B, RSV, rhinovirus, adenovirus, measles virus
● Most patients have an upper respiratory tract infection with
some combination of rhinorrhea, pharyngitis, mild cough,
and low-grade fever for 1-3 days before the signs and
symptoms of upper airway obstruction become apparent.
The child then develops the characteristic barking cough,
hoarseness, and inspiratory stridor
Signs and Symptoms
● Llow grade fever, coryza, dry, brassy, croupy or barking
cough, hoarse cry and inspiratory stridor (expiratory
stridor-subglottic structure)
● Symptoms worsen at night
● Respiratory distress
● Drooling
● Llie in recumbent position
● Physical examination can reveal a hoarse voice, coryza,
normal to moderately inflamed pharynx, and a slightly
increased respiratory rate
Page 4 of 17
PEDIATRICS (021) Respiratory Disorders Part 3 SIRMATA 2024
Diagnostics
● AP soft tissue neck radiograph
● Croup is a clinical diagnosis and does not require a
radiograph of the neck. Radiographs of the neck can show
the typical subglottic narrowing, or steeple sign, of croup
on the posteroanterior view.
● Steeple sign (Viral croup)
● Direct visualization via laryngoscopy-swelling and
hyperemia of the glottis and the subglottis

Figure 6. Tripod position seen in patient with epiglottitis

Diagnostics
● CBC-leukocytosis with neutrophilia
● BCS (Blood Culture and Sensitivity)
● Lateral neck radiograph-Thumb sign

Figure 5. Steeple Sign

Management
● Depending on the severity
● Generally supportive
● Mild cases can be observed and managed with plenty of
fluids and antipyretics
● Steam Inhalations and cool mists
● Moderate to severe cases-they need to be hospitalized for
close monitoring
● Racemic epinephrine
● Antibiotics -no benefit unless bacterial infection is Figure 7. X ray showing thumbs sign (left) and Normal X ray
implicated (right)
● Steroid use(but there are some literatures it is still
controversial) ● Direct laryngoscopy- cherry red epiglottis, swollen
● Nebulized budesonide and oral dexamethasone arytenoids and aryepiglottic folds and narrowing of the
● Oxygen (specially if their oxygens saturation is below the glottic orifice
normal) ● The diagnosis requires visualization under controlled
circumstances of a large, cherry red, swollen epiglottis by
laryngoscopy.
EPIGLOTTITIS
● Classic radiographs of a child who has epiglottitis show the
● True medical emergency thumb sign
● bacterial infection involving the supraglottic structures
particularly the epiglottis, aryepiglottic folds and false vocal Management
cords ● Ceftriaxone
● Occurs in all age groups-peak 2-7yo ● Cefotaxime
● H. influenzae type B-used to be the most common ● Chloramphenicol
etiologic agent ● Ampicillin
● Strep pyogenes, Strep pneumonia, Staph aureus, ● Adequate hyperextension of the head and neck is
Moraxella catarrhalis necessary
● High fever, severe throat pain and muffled voice ● A physician skilled in airway management and use of
● Rapid progression of symptoms- 2-4 hours intubation equipment should accompany patients with
● This now rare, but still dramatic and potentially lethal, suspected epiglottitis at all times.
condition is characterized by an acute rapidly progressive
and potentially fulminating course of high fever, sore
throat, dyspnea, and rapidly progressing respiratory Heimlich maneuver
obstruction, ● Lifesaving in case of sudden upper airway obstruction
● Ill looking, difficulty in swallowing, drooling, dysphonia, ● Complications: hypoxic ischemic encephalopathy,
respiratory distress pneumonia, septic arthritis, meningitis and pulmonary
● Severe air hunger (tripod position) edema
● The mouth is open,the neck and chin is extended and ● Prevention: HiB immunization
trunk leaning forward ● for patients in close contact with epiglottitis:HiB
● Oxygenpreventive endotracheal intubation (to support the immunization, (can take rifampin as antibiotic prophylaxis )
airway)
● Tracheostomy

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PEDIATRICS (021) Respiratory Disorders Part 3 SIRMATA 2024

Figure 8. Heimlich manuever Figure 9. Lateral radiograph showing ragged tracheal air
column
BACTERIAL TRACHEITIS (MEMBRANOUS LTB,
PSEUDOMEMBRANE CROUP) DIPHTHERIC LARYNGITIS
● Serious and contagious infection due to an extension of
●  bacterial infection of the trachea often associated with a
A
diphtheria infection from the nasal cavity, tonsils, pharynx
viral upper respiratory infection
to the larynx
● Potentially life threatening
● Sspread via direct physical contact or inhalation of infected
● Affects children 6months-8years
droplets
● MC pathogens: S. aureus, H. influenzae type B, M.
● Toxigenic strains of Corynebacterium diphtheria
catarrhalis
● Incubation period- 2-5 days
● Characterized by marked mucosal damage,
pseudomembrane formation, subglottic edema,thick
Signs and Symptoms
mucopurulent tracheal secretions
● Fever, sore throat,at, fetor oris, an in more severe
cases-membranous pharyngitis, cervical lymphadenitis
Signs and Symptoms
and a marked swelling of the soft tissues " bull neck
● Mild fever, cough, inspiratory stridor, brassy cough, neck
appearance"
pain, increasing mucopurulent respiratory secretions,
progressive res.
● The major pathologic feature appears to be mucosal
swelling at the level of the cricoid cartilage, complicated by
copious, thick, purulent secretions, sometimes causing
pseudomembranes.
● piratory obstruction, choking episodes, dysphagia

Diagnostics
● CBC- polymorphonuclear leukocytosis
● The diagnosis is based on evidence of bacterial upper
airway disease, which includes high fever, purulent airway
secretions, and an absence of the classic findings of
epiglottitis. X-rays are not needed but can show the classic
Figure 10. Patient with marked swelling of the soft tissue
findings; purulent material is noted below the cords during
endotracheal intubation
● Lateratreck radiograph- ragged tracheal air column
● Upper airway endoscopy-deep red mucosa with
ulcerations, copious thick tracheal secretions and
subglottic edema
● Endotracheal intubation and mechanical intubation(are
usually recommended to overcome airway obstruction)
● Rigid endoscopy
● Humidification
Figure 11. Patient with bull neck appearance
● Broad spectrum antibiotics IV
Diagnostics
Complications
● Bacterial smear and culture from the membrane
● Pneumonia, pneumothorax, HIE, septicemia, TSS, ARDS
Treatment
● Isolation diphtheria antitoxin antibiotics
therapy-erythromycin/penicillin
● ventilatory support

Complication
● Toxin mediated myocarditis
● Neuritis
● Pneumonia

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PEDIATRICS (021) Respiratory Disorders Part 3
RETROPHARYNGEAL ABSCESS
● Deep neck space infection
● Life threatening emergency that can cause airway
obstruction
● Infection can extend from the base of the skull into the
mediastinum and as far as the 6th thoracic vertebra
● Affects children less than 6yo
● Result from lymphatic drainge or the direct spread of
infection from adjacent areas and penetrating trauma or
instrumentation of the upper respiratory tract
● Polymicrobial
● S/Sx: fever, sorethroat,, dysphagia, odynophagia, neck
pain, limitation of neck extension or torticollis
● Clinical manifestations of retropharyngeal abscess are
nonspecific and include fever, irritability, decreased oral
intake, and drooling. Neck stiffness, torticollis, and refusal
to move the neck may also be present. The verbal child
might complain of sore throat and neck pain. Other signs
can include muffled voice, stridor, respiratory distress, or
even obstructive sleep apnea.
● A bulge in the retropharynx may be seen on PE
● Physical examination can reveal bulging of the posterior
pharyngeal wall, although this is present in <50% of infants
with retropharyngeal abscess. Cervical lymphadenopathy
may also be present.
Figure 12. Retropharynx bulge
● Soft tissue neck radiograph-widening of the prevertebral
tissue or gas in the retropharyngeal space
● CT scan helps differentiate cellulitis from abscess
● CXR- if there is mediastinal or pulmonary involvement
Figure 13. Soft tissue radiograph showing widening of the
prevertebral tissue or gas in the retropharyngeal space
Management
● Oxygen
● sniffing position
● 3rd gen cephalosporin with ampicillin sulbactam or
clindamycin
● intraoral surgical incision-if airway is compromised
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● Drainage is necessary in the patient with respiratory
distress or failure to improve with intravenous antibiotic
treatment.
Complication
● Rupture of the abscess- aspiration of pus-
asphyxia/pneumonia,sepsis, necrotizing fasciitis, jugular
vein thrombosis, erosion into the carotid artery,
mediastinitis, pericarditis, cardiac tamponade, empyema,
pleuritis, pyopneumothorax and bronchial erosions.
PERITONSILLAR ABSCESS
● A collection of pus around the tonsils
● Quinsy- a complication of tonsillitis
● predominant organisms: Strep pyogenes, Staphylococci,
Haemophilus
● affects children more than 10 yo and adults
Signs and Symtpoms
● fever, headache, worsening ing unilateral sorethroat, pain
on deglutition, halitosis, referred otalgia and neck pain
associated with tender swollen lymph nodes,
trismus(should make one highly suspicious of disease )
● Clinical manifestations include sore throat, fever, trismus,
muffled or garbled voice, and dysphagia.
● PE: bulging, hyperemic and edematous tonsil pushing the
uvula towards the uninvolved side
● Physical examination reveals an asymmetric tonsillar
bulge with displacement of the uvula

Management
● Intravenous antibiotics
● Penicillin, clindamycin,
● surgical incision and drainage done to decompress the
area and relief the pain .
● tonsillectomy- if recurrent peritonsillar abscess
● Treatment includes surgical drainage and antibiotic
therapy effective against group A streptococci and
anaerobes. Surgical drainage may be accomplished
through needle aspiration, incision and drainage, or
tonsillectomy.
Figure 14. Tonsillitis
Complications
● Septicemia, parapharyngeal abscess, mediastinitis,
aspiration of infected materials,pneumonia
● Early treatment of tonsillitis is recommended to prevent the
diseases from progressing into abscess formation
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PEDIATRICS (021) Respiratory Disorders Part 3 SIRMATA 2024

V. INFECTIONS OF THE LOWER RESPIRATORY

TRACT

BRONCHITIS
● Acute bronchitis-transient inflammatory process involving
the trachea and the main bronchi large airway of the lungs
the common clinical presentation to emergency
department or outpatient ,transient inflammatory process
involving the trachea and main bronchi
● Chronic bronchitis-persistence of symptoms beyond 2-3
weeks

VIRAL BACTERIAL Figure 15. Algorithm for the diagnosis of Viral lower respiratory
tract infection
CAUSATIVE rhinovirus, RSV, S. pn, S. aureus,
AGENTS parainfluenza, H. influenzae, M. Diagnosis
adenovirus, catarrhalis ● S/Sx: tachypnea, chest retractions, and inspiratory
paramyxovirus crackles and/or expiratory wheezing following coryzal
symptoms
● Fever, poor appetite, difficulty in sucking and restless
PHYSICAL rhonchi sleep
FINDINGS ● No laboratory examination
● CXR: more severe illness, diagnosis is unclear
DIAGNOSIS clinical CRP - ● Conditions with similar presentation: asthma, pneumonia,
Differentiate viral airway lesions, congenital lung diseases, diaphragmatic
and bacterial hernia, cystic fibrosis, CHD sepsis, and severe metabolic
acidosis
TREATMENT rest and adequate empirical
hydration Management
● Mild disease: nasal suction, frequent small feeds,
Table 1.Viral vs Bacterial bronchitis intravenous or nasogastric fluids, hypertonic saline
● Moderate to severe disease: oxygen, immediate detection
● Clinical diagnosis based on past medical history,lung and management of ventilatory failure,need to monitor the
examination and physical findings . temperature, regulation and appropriate fluid
● Oxygen saturation that plays important role in judging the administration
severity of the disease along with a pulse rate
,temperature and respiratory rate,and know the range of
respiratory rate
VI. CONGENITAL ANOMALIES OF THE UPPER
AIRWAY
Chronic bronchitis
● It may indicate: persistence of airway insult, an injury to
the airway after an initial insult, a condition that CHOANAL ATRESIA
predisposes to inflammation defect in immune defenses, ● A congenital blockage in the posterior nares due to the
underlying lung disease, psychogenic cough persistence of bony or a membranous septum
● CXR: peribronchial thickening ● Failure to pass the nasal catheter during nasal suctioning
● Treatment: directed towards the underlying cause at birth should make one suspect of the presence of
choanal atresia
● Crying relieves the cyanosis
BRONCHIOLITIS ● Endotracheal tube replacement
● A viral illness of young infant affecting the entire
respiratory tract primarily the bronchioles
● Associated with RSV infections, rhinovirus, human
metapneumovirus, human bocavirus, enterovirus,
adenovirus, influenza, human coronavirus and
parainfluenza virus

Figure 16. Normal vs Choanal atresia

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PEDIATRICS (021) Respiratory Disorders Part 3
Bilateral Atresia
● Immediate respiratory distress, asphyxia, and cyclic
cyanosis
● Seen in newborns
Unilateral Atresia
● Not recognized until several years after birth and presents
with unilateral copious nasal secretions and sinusitis
LARYNGOMALACIA
● Most common congenital laryngeal anomaly
● Due to the immaturity of the laryngeal cartilage with the
resultant weakness of the cartilaginous support of the
supraglottic larynx
● Hallmark: INSPIRATORY STRIDOR
● Becomes noticeable in the 2nd to 4th week of life
● Disappears by the 18th to 24th month
Signs and Symptoms
● Heard loudest in supine position, while feeding and during
an active or agitated state
● Signs of severe obstruction:
○ Dyspnea, cyanosis, failure to thrive
● Persistence of stridor beyond 2 years of age and the
presence of acute life threatening events warrant an
investigation of an underlying 2nd pathology
● Physical examinations focus on the head and neck
● Check the patency of the choana, you have to rule that out
● Full evaluation of the oral cavity for cleft lip or cleft palate
● They are essential because they may contribute to
breathing of feeding difficulties
● Examination of the neck is to rule out for masses or
vascular lesions which is also necessary
● Check also for possible hemangiomas
● Stridor is inspiratory, low-pitched, and exacerbated by any
exertion: crying, agitation, or feeding.
● Diagnostic Examinations: not necessary
● Proper evaluation of th e patient with suspected
laryngomalacia requires an assessment of the supraglottic
airway with flexible laryngoscopy in the awake infant
● Awake laryngoscopy: confirm the diagnosis and rule out
other congenital anomalies
● But if the patient presents with severe symptoms, the
infant should be taken to the operating room for a
diagnostic bronchoscopy
● Flexible fiber optic laryngscopy is the mainstay in the
diagnostic evaluation of infant stridor
● Direct laryngscopy and direct bronchoscopy are done in
the operating room
Two types of Laryngomalacia
● seen in the endoscopic evaluation:
1. Bending type: omega-shaped epiglottis falling backwards
2. Squeezing type: shows the arytenoids pressing and
constricting towards the center, obstructing airflow to the
glottis
Possible differential diagnosis for laryngomalacia
● Tracheomalacia
● Foreign body aspirations
● Unilateral vocal fold paralysis
Management
● Observation, reassurance, and preventive measures
● Usually the treatment of majority of the patient with
laryngomalacia is conservative, so in cases of mild or
moderate stridor without feeding difficulties observation is
recommended after making a diagnosis
● It is important to monitor for appropriate weight gain and
the development of any severe sympotms (respiratory
symptoms)
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SIRMATA 2024
● Advice positional feeding (feed the patient in the upright
position) and frequent feeding may help those infants with
feeding difficulties
● Endotracheal intubation, tracheotomy for 10 to 20% of
infants will have severe symptoms
● Epiglottoplasty (surgical intervetion): definitive procedure
● Other treatment involves treating concomitant reflux
diseases, mostly adivce proton pump inhibitors but it is not
recommended but is usually done and it help improve the
symptoms of the laryngomalacia
● Expectant observation is suitable for most infants because
most symptoms resolve spontaneously as the child and
airway grow. Laryngopharyngeal reflux is managed
aggressively with antireflux medications, such as
histamine H2 receptor antagonists (H2RAs) or proton
pump inhibitors (PPIs).
● Educate the patient by advice them on the symptoms
which is the most important for parents, they should be
made aware that treatment is mainly conservative but
close follow-up is mandatory to monitor for worsening
symptoms
Prognosis
● It resolves in the majority of patients by the age of 18 to 24
months
● Complication: acute airway compromise and respiratory
failure and even aspiration
CONGENITAL SUBGLOTTIC STENOSIS
● Second most common cause of stridor in infancy second
to laryngomalacia
● Classic symptoms: barking cough and biphasic or primarily
inspiratory stridor early in life
● Recurrent or persistent croup in infants less than 6 months
old is typical of subglottic stenosis
● Failure and difficulty of extubation serve as another clue
● Symptoms depend on the degree of obstruction
● Hoarseness is present with laryngeal involvement
● Subglottic stenosis is a narrowing of the subglottic larynx
and manifests in the infant with respiratory distress and
biphasic or primarily inspiratory stridor. It may be
congenital or acquired. Symptoms often occur with a
respiratory tract infection as the edema and thickened
secretions of a common cold narrow an already
compromised airway leading to recurrent or persistent
croup-like symptoms.
● Myer-Cotton system, with grade I through grade IV
subglottic stenosis indicating the severity of narrowing.
Dilation and endoscopic laser surgery can be attempted in
grade I and II, although they may not be effective because
most congenital stenoses are cartilaginous. Anterior
cricoid split or laryngotracheal reconstruction with cartilage
graft augmentation is typically used in grade III and IV
subglottic stenosis.
● Diagnosis: endoscopic evaluation
● Computed tomography and magnetic resonance imaging
are useful in establishing the diagnosis of subglottic
stenosis
● Also the endoscopic examination or direct endoscopic
visualization with flexible fiber optic endoscopy assess the
dynamics vocal cord function and the upper airway plus
the esophagus
Management
● Mild: observe
● Severe: anterior cricoid split, laryngeal stent replacement
or tracheotomy
● There are 3 main surgiccal approaches for subglottic
stenosis including endoscopic, open neck surgery and
tracheotomy
● Endoscopy techniques include dilataion either by balloon
or rigid dilation or stent replacement or tracheotomy
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PEDIATRICS (021) Respiratory Disorders Part 3
CONGENITAL VOCAL CORD PARALYSIS
● Usually associated with developmental CNS anomalies
and the respiratory system
● Sometimes it may be the result of the stretching of the
laryngeal nerve during delivery
● Vocal cord paralysis is the third most common congenital
laryngeal anomaly that produces stridor in infants and
children.
Signs and Symptoms
● 3 aspects are involved:
○ Phonation
○ Respiration
○ Deglutition
● Direct laryngoscopy of the dynamic larynx is
recommended
● Vocal cords may recover in 6-12 months
● Unilateral paralysis causes aspiration, coughing, and
choking; the cry is weak and breathy, but stridor and other
symptoms of airway obstruction are less common. Vocal
cord paralysis in older children may be due to a Chiari
malformation or tumors compressing the vagus or
recurrent laryngeal nerve.
SIRMATA 2024
● Ballooning of the posterior membranous wall
● Loss of the C shape ring of the trachea
Management
● Depending on the extent the diseases and other
associated conditions tracheomalacia can be treated
conservatively with medical management or with surgery
● Conservative management with adequate montiroing:
Congenital and mild acquired resolves spontaneously by
18-24 months
○ Advice parents on appropriate immunization and
passive smoking avoidance
● Supportive measures
○ Chest physiotherapy may be necessary to help the
management of secretions and prevenet airway
infections
○ Prevention and management of gastroesophageal are
mandatory
○ Specific feeding are required to avoid aspirations and
ensure adequate growth and development
● In patients with respiratory distress: CPAP
● Secondary tracheomalacia: removal of the underlying
cause

Treatment TRACHEOESOPHAGEAL FISTULA AND

● Mild symptoms: observe ESOPHAGEAL ATRESIA
● Tracheotomy for bilateral paralysis
● Laryngoplasty for unilateral paralysis
● Speech therapy with proper treatment
● For unilateral vocal cord paralysis, injection laterally to the
paralyzed vocal cord moves it medially to reduce
aspiration and related complications.
● Reinnervation procedures using the ansa cervicalis have
been successful in regaining some function of unilateral
vocal cord

TRACHEOMALACIA
● Condition characterized by the collapsibility of the trachea
caused by an intrinsically weak tracheal cartilage
● Distal third of the trachea: most affected area
● Can be congenital or intrinsic/ extrinsic or acquired

Signs and Symptoms

● Expiratory stridor or expiratory wheeze
● Cough is harsh, barky, and ineffective
● Episodic attacks of reflex apnea
● Cyanosis and dying spells
● Symptoms may be persistent or intermittent depending on
the severity and extent of the diesease
● Worsened by salbutamol nebulization
● On history taking focus on primarily on the respiratory
symptoms as wells as information regarding the perinatal
period, the prematurity, any surgical procedures or
intubation performed and feeding in both infant and young Figure 17. Normal tracheal and esophagus vs Atresia and
children Fistula
● A thorough physical examination should include a full
assessment of the head and neck as well as ● Esophageal atresia (EA) is the most common congenital
cardio-respiratory system anomaly of the esophagus
Diagnostic Tests ● Results from an incomplete separation of the primitive
● Lateral chest radiograph foregut into the respiratory and digestive tracts at the 4th
● Cinefluorscopy week of gestation
● Endoscopic evaluation of the trachea: definitive diagnosis
● Although the diagnosis is by endoscopic, diagnostic 5 Types of EA and TEF
imaging has an important role in the etiological definition ● Most common is Type C astresia with distal
especially in identifying external compressions in tracheo-esophageal fistula
secondary tracheomalacia
● Cinefluoroscopy combined with contrast swallow, this may
give information regarding the degree tracheal prolapse
and delineate esophageal abnormalities and external
tracheal compression

TRIAD
● Narrowing of the anteroposterior diameter of the trachea

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PEDIATRICS (021) Respiratory Disorders Part 3 SIRMATA 2024
● Imaging findings of absence of the fetal stomach bubble
and maternal polyhydramnios might alert the physician to
EA before birth
● Initially, maintaining a patent airway, pre-operative
proximal pouch decompression to prevent aspiration of
secretions, and use of antibiotics to prevent consequent
pneumonia are paramount

VASCULAR RING ANOMALIES

● Result from abnormalities in the aortic arch complex
● The term vascular ring is used to describe vascular
anomalies that result from abnormal development of the
aortic arch complex. The double aortic arch is the most
common complete vascular ring, encircling both the
trachea and esophagus, compressing both.
● The most common anomalies include (1) double aortic
arch, (2) right aortic arch with a left ligamentum
arteriosum, (3) anomalous innominate artery arising farther
to the left on the arch than usual, (4) anomalous left
carotid artery arising farther to the right than usual and
passing anterior to the trachea, and (5) anomalous left
FIgure 18. Types of Esophageal atresia and
pulmonary artery (vascular sling).
Tracheoesophageal fistula

Signs and Symptoms

● Present soon after birth; choking, coughing, respiratory
difficulty and cyanosis, gastric distention, continuous
vomiting, failure to thrive
● Chest radiograph: coiling of the nasal catheter at the
esophageal pouch, migratory pulmonary infiltrates and
distended stomach
● The neonate with EA typically has frothing and bubbling at
the mouth and nose after birth as well as episodes of
coughing, cyanosis, and respiratory distress. Feeding
exacerbates these symptoms, causes regurgitation, and Figure 20. Normal aortic arch complex vs vascular rings
can precipitate aspiration
Signs and Symptoms
● Biphasic stridor or expiratory wheezing
● Croupy barking cough
● Reflex apnea
● Dying spells
● Cyanosis
● Recurrent respiratory infections
● GI symptoms of dysphagia with the intake of solid food
● Double aortic arch forms a ring that completely encircles
and compresses the trachea and esophagus
● Severe type that presents in the infancy are double aortic
arch and pulmonary artery sling
● Chronic wheezing is exacerbated by crying, feeding, and
flexion of the neck. Extension of the neck tends to relieve
the noisy respiration. Vomiting may also be a component.
Affected infants may have a brassy cough, pneumonia, or
rarely, sudden death from aspiration.

Figure 19. Chest radiograph: coiling of the nasal catheter at

the esophageal pouch, migratory pulmonary infiltrates and
distended stomach

Diagnosis and Treatment

● Diagnostic endoscopy
● Constructive surgery
● Post repair problems: tracheomalacia, GER, esophageal
stricture, and repeated chemical pneumonitis
● In the setting of early-onset respiratory distress, the
inability to pass a nasogastric or orogastric tube in the
newborn suggests EA

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PEDIATRICS (021) Respiratory Disorders Part 3 SIRMATA 2024
● Chest CT scan with contrast medium - provides the
cardiovascular surgeon with a detailed anatomy of the
aortic arch abnormality
● Surgical treatment results in immediate improvement of
the symptoms which will completely resolve over time
● Cardiac catheterization is reserved for cases with
associated anomalies or in rare cases where these other
modalities are not diagnostic. Bronchoscopy may be
helpful in more severe cases to determine the extent of
airway narrowing.
● Surgery is advised for symptomatic patients who have
evidence of tracheal compression.

VII.CONGENITAL ANOMALIES OF THE LOWER

RESPIRATORY TRACT

Figure 21. Normal aortic arch complex vs double aortic arch

● Pulmonary artery sling: the left pulmonary artery arises

from the right, encircles the trachea and passes between
the trachea and esophagus producing right sided Figure 23. Normal anatomy lower respiratory tract vs
compression in the lower trachea and the right main congenital anomalies of the respiratory tract
bronchus

Figure 24. X ray showing a congenital anomaly of the

respiratory tract

PULMONARY AGENESIS/ PULMONARY APLASIA/

PULMONARY HYPOPLASIA
● Absence or incomplete development of lung tissue
● In pulmonary agenesis and pulmonary aplasia, the insult
occurs during the embryonic stage
● In pulmonary hypoplasia, the insult occurs during the
pseudoglandular or canalicular stage

Pathogenetic mechanisms
1. Inadequate fetal thoracic space due to space occupying
lesions may impinge on and prevent lung development
Figure 22. Pulmonary artery sling 2. Decreased fetal breathing
3. Insufficient amount of amniotic fluid due to leakage that
Diagnosis and Treatment disrupts long growth
● Barium esophagus - (establishes diagnosis) shows 4. Renal bladder outlet obstruction
posterior indentation up the esophagus by the vascular 5. Abnormal blood supply
ring
● Bronchoscopy - shows the compression of the Clinical Presentation
anterolateral wall of the upper trachea giving a triangular ● Depends on the extent of lung involvement and associated
shape in the lumen anatomic abnormalities

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PEDIATRICS (021) Respiratory Disorders Part 3 SIRMATA 2024
● Symptoms tend to be associated with central airway
complications of compression, stenosis, and/or
tracheobronchomalacia. In patients in whom the right lung
is absent, the aorta can compress the trachea and lead to
symptoms of central airway compression

Physical examination
● Small thorax on the affected side with or without scoliosis
or a bell shaped thorax
● Heart and midline structures may deviate ipsilaterally
● Right-sided lesion: dextrocardia must be rules out
● Percussion is dull and breath sounds are diminished

Diagnosis
● Antenatal diagnosis: UTZ/ MRI
● CT or contrast enhanced magnetic resonance angiography
● ERG and 2D echo
● The diagnosis requires a high index of suspicion to avoid
the unnecessary risks of bronchoscopy, including potential Figure 25. X ray showing congenital lobar emphysema
perforation of the rudimentary bronchus.
● CT of the chest is diagnostic, although the diagnosis may
be suggested by chronic changes in the contralateral Treatment
aspect of the chest wall and lung expansion on chest ● Options vary
radiographs ● Since congenital lobar emphysema is potentially reversible
patients with mild to moderate respiratory distress may no
Treatment require surgery however close monitoring of pulmonary
● Antenatally, fetal intrauterine surgical interventions may be status should be ensured
attempted to accelerate lung growth and prevent or reduce ● Identification and treatment of underlying cause may prove
the severity of pulmonary hypoplasia beneficial
● After birth, respiratory support may be required ● Severe life threatening: lobectomy may be life saving
● Complications: pneumothorax, repeated lower respiratory ● Treatment by immediate surgery and excision of the lobe
tract infections and chronic pulmonary insufficiency may be lifesaving when cyanosis and severe respiratory
distress are present. . Selective intubation of the
unaffected lung may be of value.
CONGENITAL LOBAR EMPHYSEMA
● Characterized by the overexpansion of a pulmonary lobe PULMONARY SEQUESTRATION
caused by intraluminal obstruction or extraluminal ● Due to non functioning pulmonary tissue that has no
compression connection with the tracheobronchial tree and derives its
● May also be idiopathic blood supply from an aberrant systemic artery from below
● Obstruct airflow during expiration, resulting in the the diaphragm
overdistention of alveoli ● We have two types: Intralobar and extralobar or
intrapulmonary and extrapulmonary
Signs and Symptoms ● The sequestration functions as a space-occupying lesion
● Easy fatigability, progressive respiratory distress, within the chest; it does not participate in gas exchange
persistent wheezing and increasing cyanosis become and does not lead to a left-to-right shunt or alveolar dead
apparent within the 1st 4 weeks of life. space
● Clinical signs range from mild tachypnea and wheeze to
severe dyspnea with cyanosis. CLE can affect one or more
lobes; it affects the upper and middle lobes, and the left
upper lobe is the most common site
● Chest examination
○ The affected side is more prominent and
hyperresonant
○ Breath sounds are decreased to absent
○ Mediastinum shifted contralaterally

Diagnosis
● CXR: hyperlucent, hyperexpanded lobe with attenuated
vascular markings, flattened hemidiaphragm, widened
intercostal space, lung herniation across the midline,
compression of the remaining lung and contralateral
mediastinal shift Figure 26. Pulmonary sequestration

INTRAPULMONARY SEQUESTRATION
● Embedded in the normal lung tissue and does not have its
own visceral pleura
● Located in the posterior basal segment of the left lower
lobe
● Presents as chronic cough, recurrent pneumonia, lung
abscess, or hemoptysis
● A chest radiograph during a period when there is no active
infection reveals a mass lesion; an air-fluid level may be
present. During infection, the margins of the lesion may be

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PEDIATRICS (021) Respiratory Disorders Part 3 SIRMATA 2024
blurred. There is no difference in the incidence of this Signs and Symptoms
lesion in each lung.
● Symptoms depend on the relative size of the lesion
EXTRAPULMONARY SEQUESTRATION ● Respiratory distress is the most common presentation at
● Presents as a homogenous mass located in the birth
retroperitoneal or subdiaphragmatic area, it has its own ● Diagnosis: may be suspected prenatally, postnatally- CXR
visceral pleura ● CT scan: identifies extent of lung involvement and the
● Patients are asymptomatic microcystic or macrocystic nature of the disease
● CXR: triangulated or homogenous mass usually on the left ● Differential diagnosis: congenital diaphragmatic hernia,
lower lobe pulmonary sequestration and congenital lobar emphysema
● Surgical removal of sequestration ● Early management in mitigating the sequelae of CCAM
● is much more common in boys and almost always involves
the left lung.
● Many of these patients are asymptomatic when the mass
CONGENITAL DIAPHRAGMATIC HERNIA
is discovered by routine chest radiography. Other patients
present with respiratory symptoms or heart failure ● A resultant abnormality when the abdominal contents are
pushed into the thoracic cavity through a defect in the
diaphragm
● Although CDH is characterized by a structural
CONGENITAL CYSTIC ADENOMATOID diaphragmatic defect, a major limiting factor for survival is
MALFORMATION the associated pulmonary hypoplasia
● Arises from pulmonary insults that occur before the 35th
day of gestation and lead to the adenomatous overgrowth
of terminal bronchiolar structures
● Congenital pulmonary airway malformation (CPAM),
previously referred to as congenital cystic adenomatoid
malformation (CCAM), is caused by abnormal branching
and hamartomatous growth of the terminal respiratory
structures that results in cystic and adenomatoid
malformations.

BOCHDALEK HERNIA
● Chest is barrel-shaped
● Breath sounds are decreased
● Sometimes, borborygmi is heard
● Abdomen is scaphoid
● Abdominal organs herniate through a defect in the
posterolateral portion of the diaphragm, commonly
involving the left
● Respiratory distress, GI symptoms, and cyanosis
● It is very important upon delivery of the baby to do
auscultation, not just the upper part of the chest and
anterior but also the posterior. You really have to listen
because you will borborygmi
● It is also very important in doing the physical examination
of the chest and abdomen to describe the organ involved
● In >50% of cases, CDH can be diagnosed on prenatal
ultrasonography (US) between 16 and 24 wk of gestation.
Figure 27. Congenital cystic adenomatoid malformation High-speed fetal MRI can further define the lesion.

Figure 29. Bochdalek hernia

Figure 28. Types of congenital cystic adenomatoid

malformation

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PEDIATRICS (021) Respiratory Disorders Part 3 SIRMATA 2024
MORGAGNI HERNIA 2. It is the most common cause of sore throat; acquired
● Results from a defect in the anterior diaphragm commonly through close contact with infected individuals.
involving the right 3. 2nd most common complication of colds; (+) swelling
● Majority is asymptomatic and erythema of the nasal mucosa and purulent nasal
discharge.
4. It is the third most common congenital laryngeal
anomaly that produces stridor in infants and children.
Usually associated with developmental CNS
anomalies and the respiratory system
5. Condition characterized by the collapsibility of the
trachea caused by an intrinsically weak tracheal
cartilage.
6. Most affected area of the condition in number 5.
7. It is a true emergency; it is dramatic and potentially
lethal, condition is characterized by an acute rapidly
progressive and potentially fulminating course of high
fever, sore throat, dyspnea, and rapidly progressing
respiratory obstruction.
8. Lifesaving maneuver of number 7 in case of sudden
upper airway obstruction.
Figure 30. Morgagni Hernia 9. It is characterized by the overexpansion of a
pulmonary lobe caused by intraluminal obstruction or
Eventration of the diaphragm extraluminal compression.
● The abdominal viscera are pushed into the thoracic cavity 10. Which type of CPAM that has an alveolar origin, can
through a thinned out portion of an intact diaphragm have small cystic areas (>0.5 cm) with solid tissue or
are mostly solid appearing.

Answers: 1. Pulmonary Sequestration 2. Acute Pharyngitis

3. Acute Sinusitis 4. Congenital Vocal Cord Paralysis 5.
Tracheomalacia 6. Distal Third Of The Trachea. 7.
Epiglottitis 8. Heimlich Maneuver 9. Congenital Lobar
Emphysema 10. Type 3

REFERENCES
Figure 31. X ray showing eventration of the diaphragm 1. Dr. Carta’s PPT Presentation (2023)
2. Nelson’s Textbook of Pediatrics.
● Can be diagnosed antenatally by using an ultrasonogram
that shows the gastrointestinal contents within the thoracic
cavity
● Surgery is the definitive treatment
● Adequate ventilatory support is essential
● ECMO (Extracorporeal membrane oxygenation) for severe
cases
● NGT: decompress the stomach
● Nutritional support
● Management of the eventration of the diaphragm depends
on the clinical symptoms and extent of lung function
disturbance
● Plication of the hemidiaphragm for symptomatic patients
with recurrent infections or pulmonary function
derangement
● Delivery at a tertiary center with experience in the
management of CDH is required to provide early,
appropriate respiratory support. In the delivery room,
infants with respiratory distress should be rapidly stabilized
with endotracheal intubation
● Prolonged mask ventilation in the delivery room, which
enlarges the stomach and small bowel and thus makes
oxygenation more difficult, must be avoided and a naso- or
orogastric tube placed immediately for decompression

TEST YOUR KNOWLEDGE

Identification:
1. This is due to non functioning pulmonary tissue that
has no connection with the tracheobronchial tree and
derives its blood supply from an aberrant systemic
artery from below the diaphragm.

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PEDIATRICS (021) Respiratory Disorders Part 3 SIRMATA 2024

APPENDIX

Figure 1. Sample Prescription

Figure 2. Algorithm for the diagnosis of Viral lower respiratory tract infection

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PEDIATRICS (021) Respiratory Disorders Part 3 SIRMATA 2024

FIgure 3. Types of Esophageal atresia and Tracheoesophageal fistula

Figure 4. Normal anatomy lower respiratory tract vs congenital anomalies of the respiratory tract

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