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Oxford Specialist
Handbooks in Paediatrics
Paediatric
Respiratory
Medicine
Second Edition

Jeremy Hull
Consultant in Paediatric Respiratory Medicine
Oxford Children’s Hospital, Oxford, UK

Julian Forton
Consultant in Paediatric Respiratory Medicine
The Children’s Hospital for Wales, Cardiff, UK

Anne Thomson
Consultant in Paediatric Respiratory Medicine
Oxford Children’s Hospital, Oxford, UK

1
3
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
Oxford University Press in the UK and in certain other countries
© Oxford University Press 205
The moral rights of the authors‌have been asserted
First edition published 2008
Second edition published 205
Impression: 
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
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rights organization. Enquiries concerning reproduction outside the scope of the
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Published in the United States of America by Oxford University Press
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Oxford University Press makes no representation, express or implied, that the
drug dosages in this book are correct. Readers must therefore always check
the product information and clinical procedures with the most up-to-date
published product information and data sheets provided by the manufacturers
and the most recent codes of conduct and safety regulations. The authors and
the publishers do not accept responsibility or legal liability for any errors in the
text or for the misuse or misapplication of material in this work. Except where
otherwise stated, drug dosages and recommendations are for the non-pregnant
adult who is not breast-feeding
Links to third party websites are provided by Oxford in good faith and
for information only. Oxford disclaims any responsibility for the materials
contained in any third party website referenced in this work.
 v

Preface to the
Second Edition
In writing this new edition, we have gone through each chapter, bringing
sections up to date, where needed, and including key new references.
Following the publication of the Global Lung Initiative prediction equations
for spirometric lung volumes, the section on lung function normal values has
been removed. Otherwise, the structure of the book is unchanged. The aim
of the handbook is to assist clinicians in the day-to-day care of children with
respiratory disease. For rarer conditions, there is perhaps more detail than
the reader might expect—this reflects our view that, when faced with a child
with a rare condition, a bit of background reading is required! The topics
covered in the book include all those required for the European Respiratory
Society Hermes exam in paediatric respiratory medicine, and so this hand-
book is a useful text for those considering taking that qualification.
JH, JF, AHT 205
vi

Preface to the
First Edition
In writing this handbook, our aim has been to provide a practical guide
to paediatric respiratory medicine that will be a useful first point of refer-
ence for paediatricians faced with children with acute or chronic respiratory
problems.
The book has been written for use by general paediatricians and by spe-
cialists in paediatric respiratory medicine at both consultant and trainee
level. It deals with common problems seen by all paediatricians and rarer
conditions more often seen at specialist centres, but managed in collabora-
tion with general paediatricians. The information is in a readily accessible
format, with extensive use of bullet points. The focus is on clinical presen-
tation, diagnosis, and management of respiratory problems. There is less
emphasis on background information, such as epidemiology and pathogen-
esis, but this is sufficient where necessary to provide insight into clinical
presentation and management, or where this information would be helpful
for parents.
The book is divided into four parts. Part  provides a practical approach
to acute and non-acute clinical problems. Part 2, the bulk of the book,
provides detailed information about common and not-so-common clinical
conditions. Part 3 provides useful information on supportive care, including,
for example, use of non-invasive ventilation and the care of a child with a
tracheostomy. Part 4 gives details on how to perform several practical pro-
cedures, such as ciliary brush biopsy, flexible bronchoscopy, and inserting
a chest drain. Finally, the appendices provide information on lung function
testing and tables of age-corrected normal values for several respiratory
parameters.
The book has been written by two consultants who work in a tertiary
respiratory unit and by a respiratory trainee. This combination of authors
has provided the experience necessary to deal with topics where there is an
absence of published evidence and to present the information in a format
that both consultants and trainees will find useful.

JH, JF, and AHT July 2007

 vii

Foreword to the
First Edition
So why would anyone want to buy a book in the 2st century, when a
profusion of information is available at the touch of a computer key? Cough
in children yields more than 6500 references on a PubMed search, so why
would anyone want to read a 5 page section on the same subject in this
book? One of the most misquoted phrases in English poetry, ‘a little learning
is a dangerous thing’ could now be adapted as ‘a lot of PubMed is a danger-
ous thing’, and unless the searcher has a sound grounding in the subject
searched, it is likely to lead to confusion in mind, an unbalanced perspective,
and ultimately, inappropriate management of children. A view of the woods
is an essential prelude to a detailed study of an individual tree.
And that is where this book will be so valuable to all in the field of pae-
diatric respiratory medicine, from the raw young tyro to the elderly pro-
fessorial dodderer, and all stages in between. The reader will find a clear
account of the subject, from both a problem-based and a disease-based
approach. It gives a commonsense overview of all the important topics in
the field, with crisp tables and bullet points, written in clear English. There
are a few, up-to-date papers, reviews and websites as a basis for further
learning, and the authors have fully achieved their aim, of writing a practical
handbook in line with the long tradition of the Oxford series. The trainee can
rapidly acquire a good grasp of the subject, and can then safely dive into
PubMed for more advanced studies, particularly of pathophysiology. Few if
any of the allegedly trained will read this without finding something to learn,
or some new idea not previously thought of, to try when next a problem
arises. Few will agree with absolutely every statement, but that is inevitable
and part of the intrinsic beauty of the subject—and in any event, medicine
is learned by doing, and cannot be learned solely from books, whatever the
views of those currently changing medical training with all the natural talent
of a hippopotamus playing the piccolo.
So in summary, who can benefit from this book, and how? The trainee will
certainly not outgrow it—even the most experienced paediatrician, seeing
a child with an uncommon condition, or preparing a teaching session on a
common one, will benefit from taking a surreptitious peek at the relevant
section here, to ensure nothing has been forgotten. For example, I would
challenge the reader to list the totality of the associated conditions which
need to be detected in a baby with a PHOX2b mutation before turning to
Chapter 26. Review copies of books come into three categories: ‘throw
away’, ‘give away’ and ‘chain it to the wall’—this Handbook is definitely in
the last category. Departmental thieves, hands off!

Andy Bush
Professor of Paediatric Respirology
Royal Brompton Hospital
London
viii

Acknowledgements

We gratefully acknowledge the skill and patience of Professor Sir David

Hull who drew most of the figures.
 ix

Contents

Symbols and abbreviations xiii

Part I Approach to clinical problems

 Examining the respiratory system 3
2 Poorly controlled asthma 
3 Recurrent or persistent ‘chest infection’ 7
4 Chronic cough 23
5 Stridor 3
6 Infant apnoea 39
7 Cystic fibrosis: poor weight gain 45
8 Cystic fibrosis: loss of lung function 5
9 Chest pain 55
0 Haemoptysis 6
 The immunocompromised child 67
2 Muscle weakness 73
3 Pneumonia on the intensive care unit 79

Part II Specific conditions

4 Asthma 87
5 Cystic fibrosis 3
6 Respiratory pathogens 55
7 Community-acquired pneumonia 63
8 Bacterial infections 77
9 Viral infections 207
20 Fungal infections 239
2 Parasitic and protozoal infections 249
22 Tuberculosis 257
x CONTENTS

23 Human immunodeficiency virus infection 279

24 Structural problems of upper and lower airways 287
25 Sleep-disordered breathing and other
sleep problems 323
26 Respiratory control disorders 335
27 Sudden infant death syndrome 353
28 Apparent life-threatening events 357
29 Cerebral palsy 359
30 Gastro-oesophageal reflux and aspiration
lung disease 365
3 Foreign body aspiration 375
32 Inhalational lung disease 38
33 Non-cystic fibrosis bronchiectasis 387
34 Primary ciliary dyskinesia 397
35 Primary immune deficiency 407
36 Post-infectious bronchiolitis obliterans 425
37 Pleural effusion 43
38 Pneumothorax 439
39 Chronic lung disease of prematurity 449
40 Chest wall deformity and scoliosis 457
4 Congenital lung anomalies 469
42 Craniofacial abnormalities 487
43 Atopic eczema and allergic rhinitis 497
44 Food allergy 503
45 Heart disease 509
46 Interstitial lung disease 55
47 Hypersensitivity pneumonitis 525
48 Neuromuscular weakness 53
49 Thoracic tumours 555
 CONTENTS xi

50 Pulmonary complications of cancer treatment 567

5 Pulmonary hypertension 575
52 Pulmonary infiltrates with eosinophilia 583
53 Sickle-cell disease 589
54 Rare diseases affecting the lungs or airway 595
55 Lung transplantation 639

Part III Supportive care

56 Use of oxygen 653
57 Inhalers and nebulizers 665
58 Airway clearance techniques 673
59 Immunization 68
60 Dealing with non-adherence to therapy 685
6 Non-invasive ventilation 689
62 Tracheostomy 697

Part IV Practical procedures

63 Airway management 707
64 Bronchoscopy 77
65 Chest drains 727
66 Changing a tracheostomy tube 73
67 Ciliary brush biopsy 735
68 Lower airway samples 739
69 Exercise testing 743
70 Exhaled and nasal nitric oxide measurement 749
7 Skin prick testing 753

Appendices
 Blood gases and acid–base balance 759
2 Fitness to fly 763
xii CONTENTS

3 Polysomnography 767
4 Measuring lung function 777
5 Lung function: reference values 795

Index 798
 xiii

Symbols and abbreviations

± plus/minus
= equal to
> more than
< less than
≥ equal to or more than
≤ equal to or less than
% per cent
β beta
γ gamma
£ pound sterling
°C degree Celsius
®
registered
™ trademark
AAD adaptive aerosol delivery
AAT alpha- antitrypsin
ABG arterial blood gas
ABPA allergic bronchopulmonary aspergillosis
ACBT active cycle of breathing technique
ACD alveolar capillary dysplasia
ACE angiotensin-converting enzyme
Ach acetylcholine
AChE acetylcholinesterase
AChR acetylcholine receptor
ACM Arnold–Chiari malformation
ACS acute chest syndrome
ADA adenosine deaminase
ADHD attention-deficit/hyperactivity disorder
AHI apnoea hypopnoea index
AIDS acquired immune deficiency syndrome
ALL acute lymphoblastic leukaemia
ALT alanine aminotransferase
ALTE apparent life-threatening event
ANA antinuclear antibody
ANCA antineutrophil cytoplasmic antibody
ANSD autonomic nervous system dysregulation
APTT activated partial thromboplastin time
xiv SYMBOLS AND ABBREVIATIONS

ARDS acute respiratory distress syndrome

ART antiretroviral therapy
AS adolescent scoliosis
ASD atrial septal defect
AST aspartate aminotransferase
AT ataxia telangiectasia
atm atmosphere
ATP adenosine triphosphate
ATS American Thoracic Society
AXR abdominal X-ray
BAL bronchoalveolar lavage
BCG bacille Calmette–Guérin
BD Behçet’s disease
BE base excess
BHL bilateral hilar lymphadenopathy
BIPAP bilevel positive airway pressure
BMD bone mineral density; Becker muscular dystrophy
BMI body mass index
BO bronchiolitis obliterans
BOOP bronchiolitis obliterans and organizing pneumonia
BOS bronchiolitis obliterans syndrome
BPD bronchopulmonary dysplasia
bpm beats per minute
BSLT bilateral sequential lung transplantation
BTS British Thoracic Society
Ca calcium
c-ANCA cytoplasmic antineutrophil cytoplasmic antibody
CBF ciliary beat frequency
CCAM congenital cystic adenomatoid malformation
CCHS congenital central hypoventilation syndrome
CDC Centers for Disease Control and Prevention
CEA carcinoembryonic antigen
CF cystic fibrosis
CFC chlorofluorocarbon
CFRD cystic fibrosis-related diabetes
CGD chronic granulomatous disease
CHARGE coloboma, heart defects, atresia choanae, retarded growth
and development, genital hypoplasia, ear abnormalities
ChAT choline acetyl transferase
chILD children’s interstitial and diffuse lung disease
 SYMBOLS AND ABBREVIATIONS xv

CIP chronic interstitial pneumonitis

CLAD chronic lung allograft dysfunction
CLD chronic lung disease (of prematurity)
CLE congenital lobar emphysema
cmH2O centimetre of water
CMI cell-mediated immunity
CMV cytomegalovirus
CNS central nervous system
CO carbon monoxide
CO2 carbon dioxide
COHb carboxyhaemoglobin
CPAM congenital pulmonary airway malformation
CPAP continuous positive airway pressure
CPF cough peak flow
CRP C-reactive protein
CSF cerebrospinal fluid
CT computed tomography
CVID common variable immune deficiency
CXR chest X-ray
DEXA dual-energy X-ray absorptiometry
DIOS distal intestinal obstruction syndrome
DIP desquamative interstitial pneumonitis
dL decilitre
DMD Duchenne muscular dystrophy
DNA deoxyribonucleic acid
2,3-DPG 2,3-diphosphoglycerate
DPI dry powder inhaler
DRV daily recommended value
dsDNA double-stranded deoxyribonucleic acid
EBV Epstein–Barr virus
ECG electrocardiogram
ECMO extracorporeal membrane oxygenation
EEG electroencephalography
ELISA enzyme-linked immunosorbent assay
ELS extralobar sequestration
EM electron microscopy
EMG electromyography
ENaC epithelial sodium channel
ENT ear, nose, and throat
ERS European Respiratory Society
xvi SYMBOLS AND ABBREVIATIONS

ESR erythrocyte sedimentation rate

ETT endotracheal tube
F French
FBC full blood count
FEES fibreoptic endoscopic evaluation of swallowing
FEF forced expiratory flow
FENO fractional exhaled nitric oxide
FEV forced expiratory volume in  second
FFP fresh frozen plasma
FGFR fibroblast growth factor receptor
FiO2 fraction of inspired oxygen
FISH fluorescent in situ hybridization
FRC functional residual capacity
ft foot/feet
FVC forced vital capacity
g gram
GAG glucosaminoglycan
GAS group A Streptococcus
GBS Guillain–Barré syndrome
GCR glucocorticoid receptor
G-CSF granulocyte colony-stimulating factor
GD Gaucher’s disease
GH growth hormone
GI gastrointestinal
GINA Global Initiative for Asthma
GLI Global Lung Initiative
GM-CSF granulocyte macrophage colony-stimulating factor
GOR gastro-oesophageal reflux
GORD gastro-oesophageal reflux disease
GP general practitioner
GTT glucose tolerance test
GVHD graft-versus-host disease
h hour
HAART highly active antiretroviral therapy
Hb haemoglobin
HBoV human bocavirus
HCG human chorionic gonadotrophin
HDU high dependency unit
HEPA high-efficiency particle arrest
HFCWO high-frequency chest wall oscillation
 SYMBOLS AND ABBREVIATIONS xvii

Hib Haemophilus influenzae type b

HIV human immunodeficiency virus
HLA human leucocyte antigen
HMP human metapneumovirus
HP hypersensitivity pneumonitis
HPV human papillomavirus
HRCT high-resolution computed tomography
HVA homovanillic acid
IC inspiratory capacity
ICU intensive care unit
Ig immunoglobulin
IGF insulin growth factor
IGT interferon-gamma test
IL interleukin
ILD interstitial lung disease
ILS intralobar sequestration
IM intramuscular
IPH idiopathic pulmonary haemosiderosis
IQ intelligence quotient
IRT immune-reactive trypsin
ITP idiopathic thrombocytopenic purpura
IU international unit
IUGR intrauterine growth retardation
IV intravenous
IVC inferior vena cava
IVIg intravenous immunoglobulin
JATD Jeune asphyxiating thoracic dystrophy
JCVI Joint Committee on Vaccination and Immunisation
JDM juvenile dermatomyositis
JIA juvenile idiopathic arthritis
JORRP juvenile onset recurrent respiratory papillomatosis
K potassium
kcal kilocalorie
kCO transfer factor
kg kilogram
kPa kilopascal
L litre
LABA long-acting beta-agonist
LAM lymphangioleiomyomatosis
LCFA long-chain fatty acid
xviii SYMBOLS AND ABBREVIATIONS

LCH Langerhans cell histiocytosis

LCI lung clearance index
LCT long-chain triglyceride
LDH lactate dehydrogenase
LIP lymphoid interstitial pneumonitis
LOW late-onset wheeze
LRTI lower respiratory tract infection
LTEC laryngotracheo-oesophageal cleft
LTOT long-term oxygen therapy
m metre
MBC maximum breathing capacity
MCFA medium-chain fatty acid
MCT medium-chain triglyceride
MDI metered-dose inhaler
MDR multidrug resistance
mEq milli equivalent
mg milligram
Mg magnesium
MG myasthenia gravis
min minute
mL millilitre
MLS middle lobe syndrome
mm millimetre
mmHg millimetre of mercury
mmol millimole
mph mile per hour
MPS mucopolysaccharidoses
MRA magnetic resonance angiography
MRI magnetic resonance imaging
mRNA messenger ribonucleic acid
MRSA meticillin-resistant Staphylococcus aureus
MSSA meticillin-sensitive Staphylococcus aureus
MTB Mycobacterium tuberculosis
mTOR mammalian target of rapamycin
Na sodium
NBT nitroblue tetrazolium
NEB neuroepithelial body
NEHI neuroendocrine hyperplasia of infancy
NG nasogastric
NHL non-Hodgkin’s lymphoma
 SYMBOLS AND ABBREVIATIONS xix

NHS National Health Service

NICE National Institute for Health and Care Excellence
NIH National Institutes of Health
NIPPV non-invasive positive pressure ventilation
NIV non-invasive ventilation
NK natural killer
nmol nanomole
NO nitric oxide
NPA nasopharyngeal aspirate
NPARM non-polyalanine repeat mutation
NPD Niemann–Pick disease
NREM non-rapid eye movement
NSAID non-steroidal anti-inflammatory drug
NSIP non-specific interstitial pneumonitis
NTM non-tuberculous mycobacteria
OGTT oral glucose tolerance test
OP organizing pneumonia
OSA obstructive sleep apnoea
PAA pulmonary artery aneurysm
p-ANCA perinuclear antineutrophil cytoplasmic antibody
PAP pulmonary alveolar proteinosis
PARM polyalanine repeat expansion mutation
PAS periodic acid–Schiff
PBMC peripheral blood mononuclear cell
PC pectus carinatum
PCD primary ciliary dyskinesia
PCP pneumocystis pneumonia
PCR polymerase chain reaction
PCV pneumococcal conjugate vaccine
PE pectus excavatum; pulmonary embolism
PEEP positive end-expiratory pressure
PEFR peak expiratory flow rate
PEP positive expiratory pressure
PIE pulmonary infiltrates with eosinophilia
PIG pulmonary interstitial glycogenesis
PIV parainfluenza virus
PL pulmonary lymphangiectasia
PLMD periodic limb movement disorder
PLMS periodic limb movement in sleep
PMA post-menstrual age
xx SYMBOLS AND ABBREVIATIONS

PMD Pelizaeus–Merzbacher disease

PNEC pulmonary neuroendocrine cell
PNET primitive neuroectodermal tumour
PNP purine nucleoside phosphorylase
ppb part per billion
PPHN persistent pulmonary hypertension of the newborn
PPV pneumococcal polysaccharide vaccine
PSG polysomnography
PTH parathyroid hormone
PTLD post-transplant lymphoproliferative disease
PW persistent wheeze
PWS Prader–Willi syndrome
RADS reactive airways dysfunction syndrome
RAST radioallergosorbent test
RCT randomized controlled trial
RDS respiratory distress syndrome
REM rapid eye movement
RhF rheumatoid factor
RLS restless legs syndrome
RNA ribonucleic acid
RPO re-expansion pulmonary oedema
RSS rigid spine syndrome
RSV respiratory syncitial virus
RV right ventricular; residual volume
s second
SaO2 oxygen saturation
SARS severe acute respiratory syndrome
SARS-CoV severe acute respiratory syndrome-associated coronavirus
SC subcutaneous
SCD sickle-cell disease
SCID severe combined immunodeficiency
SCT stem cell transplantation
SD standard deviation
SIDS sudden infant death syndrome
SIT specific immunotherapy
SLE systemic lupus erythematosus
SMA spinal muscular atrophy
SMARD spinal muscular atrophy with respiratory distress
SPA suprapubic aspiration
SPB surfactant protein B
 SYMBOLS AND ABBREVIATIONS xxi

SPC summary of product characteristics

SPT skin prick test
SSRI selective serotonin reuptake inhibitor
SVC superior vena cava
TAPVD total anomalous pulmonary venous drainage
TB tuberculosis
TBI total body irradiation
TBM tuberculous meningitis; tracheobronchomalacia
TCS Treacher Collins syndrome
TEW transient episodic wheeze
Th T-helper
TIM target inhalation mode
TLC total lung capacity
TLCO total lung carbon monoxide
TMP-SMZ trimethoprim–sulfamethoxazole
TNF tumour necrosis factor
TOF tracheo-oesophageal fistula
tPa tissue plasminogen activator
TPE tuberculous pleural effusion
TPN total parenteral nutrition
TRALI transfusion-related acute lung injury
TSNS tumours of the sympathetic nervous system
TST tuberculin skin test
TTN transient tachypnoea of the newborn
TU tuberculin unit
U unit
U&E urea and electrolyte
UK United Kingdom
UIP usual interstitial pneumonitis
URTI upper respiratory tract infection
USA United States of America
VAP ventilator-associated pneumonia
VATS video-assisted thoracoscopic surgery
VC vital capacity
VCD vocal cord dysfunction
VEGF vascular endothelial growth factor
VEPTR vertical expandable prosthetic titanium rib
VHC valved holding chamber
VMA vanillylmandelic acid
VPI velopharyngeal incompetence
xxii SYMBOLS AND ABBREVIATIONS

V/Q ventilation/perfusion
VSD ventricular septal defect
VZV varicella-zoster virus
WASP Wiskott–Aldrich syndrome protein
WBC white blood count
WG Wegener’s granulomatosis
WHO World Health Organization
XDT-TB extreme drug resistance
ZIG zoster immunoglobulin
 Part I

Approach to
clinical problems

 Examining the respiratory system 

2 Poorly controlled asthma 
3 Recurrent or persistent ‘chest infection’ 7
4 Chronic cough 23
5 Stridor 3
6 Infant apnoea 39
7 Cystic fibrosis: poor weight gain 45
8 Cystic fibrosis: loss of lung function 5
9 Chest pain 55
0 Haemoptysis 6
 The immunocompromised child 67
2 Muscle weakness 73
3 Pneumonia on the intensive care unit 79
 Chapter  3

Examining the
respiratory system

Introduction 4
Clubbing 4
Chest shape 4
Palpation 5
Percussion 6
Stridor 6
Stertor 6
Auscultation 7
Listen to the cough 9
4 Chapter  Examining the respiratory system

Introduction
Examining the chest is part of the routine physical examination of all chil-
dren who are unwell. Most doctors are expert at identifying the abnormal
signs that indicate disease. This short section provides the background to
a common language so that clear descriptions can be given to colleagues.

Clubbing
• Gross clubbing is easy to recognize. Early clubbing is more subtle with
an impression of fullness and ‘floating’ of the root of the nail bed on
compression.
• The mechanisms that underlie the development of clubbing remain
unclear. Possibilities include circulating mediators of vasodilatation
released in response to hypoxia, and effects of the vagal nerve resulting
from the observation of the association between clubbing and disease in
organs with vagal innervation.
• In children with respiratory symptoms, clubbing usually suggests
suppurative lung disease or cyanotic cardiac disease. It can also be seen
in children with chronic hypoxaemia from a respiratory cause such as
interstitial lung disease (ILD) or bronchiolitis obliterans (BO).

Chest shape
• Fixed variations of the chest shape are relatively common in children,
affecting 0.5% of the population. They usually have no significant
functional consequences. The commonest variation is pectus excavatum
(see E Chapter 40). It is best to avoid the term ‘chest deformity’ in
describing normal variations of the chest shape.
• Hyperinflation (Fig. .) is a reversible change in the chest shape and
indicates air trapping, usually as a result of small airways obstruction. In
the context of asthma, it suggests poor control. It is most easily seen
from the side.
• Harrison’s sulci (Fig. .2) refer to an indentation of the lower chest wall
with the apparent splaying of the costal margins. They may be seen
in association with hyperinflation. They are associated with chronic
respiratory disease associated with increased work of breathing and
may be caused by the necessarily increased power of diaphragmatic
contraction on relatively soft costal cartilage.
 Palpation 5

Back Front

Normal Hyperinflated

Fig. . Lateral view of the normal and hyperinflated chest.

Pectus excavatum Harrison’s sulci (arrow)

Fig. .2 Anterior views of pectus excavatum and Harrison’s sulci.

Palpation
• Placing the hands on the chest can give valuable information about the
presence of secretions and wheeze. It can also help determine whether
chest expansion is symmetrical.
• In older children who can perform a vital capacity manoeuvre,
measuring the chest expansion, using a tape measure at the level of
the xiphoid cartilage, can be predictive of lung volumes measured by
spirometry. Depending on the height and sex of the subject, normal
values for chest expansion can range from 3 cm to 9 cm.
6 Chapter  Examining the respiratory system

Percussion
Despite occasional views to the contrary, it is always useful to percuss the
chest in children. A dull percussion note is consistent with extensive consoli-
dation or pleural disease, either pleural thickening or pleural fluid.

Stridor
Stridor (from the Latin stridere, to make harsh sounds) is a harsh mono-
phonic noise that comes from the trachea or larynx as a result of narrowing.
It may be heard with or without a stethoscope. When the extrathoracic
airway is affected, the noise always has an inspiratory component but can
be biphasic if the narrowing is severe. When the intrathoracic trachea is
affected, the stridor will usually be biphasic, with a relatively loud expiratory
phase. A purely inspiratory stridor indicates narrowing of the extrathoracic
airway. Stridor is louder when airflows are increased, such as with crying or
exertion, and quieter when flows are reduced, e.g. during sleep.

Stertor
This term is used to describe the harsh coarse noises generated by turbu-
lent airflow in the supraglottic space. It may be caused by spasticity of the
pharyngeal muscles, e.g. in a child with cerebral palsy, by retained secre-
tions, or by adenotonsillar hypertrophy. Stertor is often louder during sleep,
because of reduced tone of the pharyngeal muscles.
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 ERICA spicata.

CHARACTER SPECIFICUS.

Erica, antheris aristatis, inclusis; floribus pluribus, dense spicatis,

subterminalibus; foliis subsenis.

DESCRIPTIO.

Caulis fruticosus, pedalis, erectus, ramis pluribus, confertis,

adscendentibus.
Folia subsena, linearia, mucronata, patentia, glaberrima, subtus sulcata,
petiolis brevissimis, cauli adpressis.
Flores plures, subterminales arcte stipati, in spicam duram; ima parte
luteoli, summa virescens.
Calyx. Perianthium persistens, duplex; exterius polyphyllum, foliolis
lanceolatis, inæqualibus; interius tetraphyllum, flavescens, foliolis aduncis,
spathulatis, summa inflata, callosa, acuminata, connivente.
Corolla teretiuscula, basi attenuata, ore obtuso, quadrifido, æquali,
connivente.
Stamina. Filamenta octo, capillaria, corollæ subæqualia, receptaculo
inserta. Antheræ aristatæ, inclusæ.
Pistillum. Germen subrotundum. Stylus filiformis, staminibus longior.
Stigma tetragonum.
Habitat ad Caput Bonæ Spei.
Floret a Novembri in Aprilem.

REFERENTIA.

1. Calyx et Corolla.
2. Calyx et Bractea lente aucta.
 3. Stamina et Pistillum.
4. Stamina a Pistillo diducta, anthera una lente aucta.
5. Stylus et Stigma lente aucta.

SPECIFIC CHARACTER.

Heath, with bearded tips, within the blossoms; which are numerous, on a
close spike, nearly terminating the branches; leaves growing mostly by
sixes.

DESCRIPTION.

Stem shrubby, growing a foot high, upright, with numerous, crowded,

undivided, and ascending branches.
Leaves growing mostly by sixes, sharp-pointed, spreading, and smooth,
channelled underneath, and pressed to the stem by short foot-stalks.
Flowers numerous, growing nearly at the end of branches, in hard
close-set spikes; the lower part of a light yellow, the extremity of a light
green.
Empalement. Cup permanent, double; the outer many-leaved, unequal,
and spear-shaped; the inner four-leaved, which are yellow, crooked, and
spatula-shaped; their upper part hard, inflated, sharp-pointed, and tending to
each other.
Blossom somewhat cylindrical, with a tapered base; the mouth blunt,
and divided into a four-cleft, equal border, whose segments tend to each
other.
Chives. Eight hair-like threads, nearly of a length with the blossom, fixed
into the receptacle. Tips bearded, and within the blossom.
Pointal. Seed-vessel roundish. Shaft thread-shaped, and longer than the
threads. Summit four-cornered.
Native of the Cape of Good Hope.
In bloom from November till April.

REFERENCE.
1. The Empalement with the Blossom.
2. The Empalement and Floral-leaves magnified.
3. The Chives and Pointal.
4. The Chives detached from the Pointal, one tip magnified.
5. The Shaft and its Summit magnified.
 ERICA spuria.

CHARACTER SPECIFICUS.

Erica, antheris muticis, inclusis; stylo exserto; corollis sub-cylindricis,

dilute purpureis; laciniis revolutis; floribus terminalibus, sub-quaternis;
foliis quaternis, sub-ciliatis.

DESCRIPTIO.

Caulis fruticosus, pedalis, ramosus; ramuli numerosi, sub-erecti.

Folia quaterna, linearia, sub-ciliata, subtus sulcata; petiolis brevissimis,
adpressis.
Flores in apicibus ramulorum sessiles, sub-quaterni; pedunculi
brevissimi, bracteis tribus minutis instructi.
Calyx. Perianthium tetraphyllum, foliolis subulatis, carinatis, adpressis.
Corolla sub-cylindrica, pollicaris, dilute purpurea; laciniis sub-ovatis,
acutis, revolutis; ore parum arctato.
Stamina. Filamenta octo capillaria, corollâ breviora; antheræ muticæ,
inclusæ.
Pistillum. Germen ovatum, sulcatum. Stylus filiformis, exsertus. Stigma
tetragonum.
Habitat ad Caput Bonæ Spei.
Floret a mense Aprili in Augustum.

REFERENTIA.

1. Calyx et Corolla.
2. Calyx lente auctus.
3. Stamina et Pistillum.
4. Stamina a Pistillo diducta; anthera una lente aucta.
 5. Stylus et Stigma, lente aucta.

SPECIFIC CHARACTER.

Heath, with beardless tips, within the blossom; shaft without; blossoms
nearly cylindrical, of a light purple; segments of the border rolled back;
flowers terminate the smaller branches, mostly by fours; leaves grow by
fours, a little hairy at the edges.

DESCRIPTION.

Stem shrubby, grows a foot high, and branching; the small branches are
numerous, and nearly upright.
Leaves grow by fours, are linear, a little hairy, furrowed beneath; with
very short foot-stalks pressed to the branches.
Flowers grow at the end of the small branches, generally by fours, and
sitting close upon them; footstalks very short, having three very small floral
leaves.
Empalement. Cup of four leaves, which are awl-shaped, keeled, and
pressed to the blossom.
Blossom nearly cylindrical, an inch long, and of a light purple; segments
of the border nearly egg-shaped, sharp-pointed, and rolled back; the mouth a
little narrowed.
Chives. Eight hair-like threads, shorter than the blossom; tips beardless,
and within the blossom.
Pointal. Seed-bud egg-shaped and furrowed. Shaft thread-shaped, and
without the blossom. Summit four-cornered.
Native of the Cape of Good Hope.
Flowers from the month of April till August.

REFERENCE.

1. The Empalement and Blossom.

2. The Empalement magnified.
3. The Chives and Pointal.
4. The Chives detached from the Pointal; one tip magnified.
5. The Shaft and Summit, magnified.
 ERICA taxifolia.

CHARACTER SPECIFICUS.

Erica antheris muticis, inclusis; floribus spicato-umbellatis, terminalibus;

corolla ventricosa, ore arctata, calyce colorato, fere tecta, limbo patente;
foliis rigidis, ternis, trigonis, mucronatis, sexsariam imbricatis.

DESCRIPTIO.

Caulis fruticosus, erectus, ramosissimus; rami et ramuli patento-erecti,

valde cicatrisati.
Folia terna, trigona, glabra, linearia, rigida, mucronata, sexsariam
imbricata; petiolis brevissimis, adpressis.
Flores in apicibus ramulorum umbellati, numerosi, erecti; pedunculi
colorati, longitudine corollarum; bracteæ duæ supra medium pedunculi,
tertia vero ad basin.
Calyx. Perianthium tetraphyllum, foliolis ovatis, mucronatis, concavis,
membranaceis, coloratis, longitudine sere corollæ.
Corolla ventricosa, ore arctata, carnea; laciniis patentibus, mucronatis,
semi ovatis.
Stamina. Filamenta octo, capillaria, curvata. Antheræ muticæ, inclusæ,
flavæ.
Pistillum. Germen subrotundum, sulcatum. Stylus inclusus, filiformis.
Stigma peltato-tetragonum.
Habitat ad Caput Bonæ Spei.
Floret a mensi Augusti, in Novembrem.

REFERENTIA.

1. Calyx et Corolla.
 2. Calyx, lente auctus.
3. Corolla.
4. Stamina, et Pistillum.
5. Stamina a Pistillo diducta, anthera una lente aucta.
6. Pistillum, auctum.

SPECIFIC CHARACTER.

Heath with beardless tips, within the blossom; the flowers terminate the
branches in umbels, forming a spike; blossom swelled at the base, pinched
in at the top, and almost covered by a coloured cup, with the border
spreading; leaves grow by threes, harsh, three-sided, sharp-pointed, and tiled
in six divisions round the stem.

DESCRIPTION.

Stem shrubby, upright, very branching; the larger and smaller branches
grow spreading, and upright, and are very much notched.
Leaves grow by threes, three-sided, smooth, linear, harsh, sharp-pointed,
and tiled in six divisions; with very short foot-stalks, pressed to the
branches.
Flowers grow at the ends of the small branches in umbels, numerous
and upright; foot-stalks coloured, the length of the blossoms; two floral
leaves upon the middle of the foot-stalk, and the third at its base.
Empalement. Cup four-leaved, leaflets egg-shaped, pointed, concave,
skinny, and coloured, nearly the length of the blossom.
Blossom swelled at the base, narrowed at the mouth, and flesh coloured;
segments spreading, pointed, and half egg-shaped.
Chives. Threads eight, hair-like, and curved. Tips beardless, within the
blossom, and yellow.
Pointal. Seed-bud roundish, and furrowed. Shaft within the blossom,
and thread-shaped. Summit between shield and four-cornered.
Native of the Cape of Good Hope.
Flowers from August till November.
 REFERENCE.

1. The Empalement, and Blossom.

2. The Empalement, magnified.
3. The Blossom.
4. The Chives, and Pointal.
5. The Chives detached from the Pointal, one Tip magnified.
6. The Pointal, magnified.
 ERICA tubiflora.

CHARACTER SPECIFICUS.

Erica, antheris muticis, sub-exsertis, floribus sub-solitariis, sessilibus,

terminalibus; corollis clavato-cylindricis, curvatis, pubescentibus; foliis
quaternis, tenuibus, ciliatis.

DESCRIPTIO.

Caulis flexibilis, erectus, superne tomentosus; rami sparsi, filiformes,

frequentes, villosi; ramuli frequentissimi brevissimi.
Folia quaterna, tenuia, obtusa, ciliata, subtus sulcata.
Flores sessiles, in ramulis terminates, sub-solitarii, patenti, racemum
quasi formantes longum.
Calyx. Perianthium tetraphyllum, foliolis spathulatis, ciliatis, pedunculis
fere nullis, bracteis tribus adpressis.
Corolla clavata, curvata, villosa, carnea oris laciniis acutis, reflexis.
Stamina. Filamenta octo capillaria. Antheræ muticæ, sub-exsertæ.
Pistillum. Germen pedicillatum, sub-globosum, profunde sulcatum.
Stylus filiformis, apice curvatus, exsertus. Stigma obsolete tetragonum.
Habitat ad Caput Bonæ Spei.
Floret a mensi Aprili, in Julium.

REFERENTIA.

1. Folium, auctum.
2. Calyx.
3. Calyx, auctus.
4. Corolla.
5. Stamina, et Pistillum, anthera una lente aucta.
 6. Pistillum.
7. Pistillum, auctum.

SPECIFIC CHARACTER.

Heath, with beardless tips, within the blossom; flowers grow mostly singly
at the end of the branches; blossoms between club and cylindar-shaped,
curved and downy; leaves grow by fours, thin and fringed with hairs.

DESCRIPTION.

Stem flexible, upright, and downy at the upper part; branches scattered,
thread shaped, numerous and hairy, the smaller branches are very numerous
and very short.
Leaves grow by fours, are thin, blunt, fringed with hair at the edges, and
furrowed beneath.
Flowers sit close upon the ends of the small branches, mostly solitary,
and spreading, appearing like a long bunch.
Empalement. Cup four leaves, leaflets spatula-shape and fringed, with
scarce any foot-stalks; three floral leaves pressed to the blossom.
Blossom club-shaped, curved, hairy and flesh-coloured; the segments of
the border pointed, and reflexed.
Chives. Eight hair-like threads. Tips beardless, and just without the
blossom.
Pointal. Seed-bud growing on a foot-stalk nearly globular, and deeply
furrowed. Shaft thread-shaped, curved at the end, and without the blossom.
Summit obscurely four-cornered.
Native of the Cape of Good Hope.
Flowers from April till July.

REFERENCE.

1. A Leaf, magnified.
2. The Empalement.
3. The Empalement, magnified.
4. The Blossom.
5. The Chives, and Pointal, one tip magnified.
6. The Pointal.
7. The Pointal, magnified.
 ERICA ventricosa.

CHARACTER SPECIFICUS.

Erica, antheris basi bicornibus inclusis; corollis oblongo-ovatis, ventricosis,

glabris; foliis quaternis ciliatis.

DESCRIPTIO.

Caulis fruticosus, semipedalis, teres, crassiusculus, ramosissimus, ramis

recurvato-adscendentibus.
Folia quaterna, linearia, acuta, basi recurvata, apice adscendentia,
ciliata, supra plana, subtus revoluta, nitida, petiolis brevissimis adpressis.
Flores terminales, plures, fastigiati, erecti; pedunculi purpurei, basi
instructa bracteis binis, parvis, oppositis.
Calyx. Perianthium tetraphyllum foliolis erectis, carinatis, ciliatis.
Corolla oblongo-ovata, apice arctata, limbo æquali, quadrilobo,
subreflexo, albo-purpurascens, glabra, nitida.
Stamina. Filamenta octo capillaria, corollæ subæqualia, receptaculo
inserta. Antheræ inclusæ, parvæ, bifidæ, basi bicornes.
Pistillum. Germen, oblongum, sulcatum. Stylus filiformis, filamentis
æqualis; stigma sub-tetragonum.
Habitat ad Caput Bonæ Spei.
Floret a mensi Aprili ad Septembrem.

REFERENTIA.

1. Calyx, et Corolla.
2. Calyx, et Bractea lente aucta.
3. Stamina, et Pistillum.
4. Stamina a Pistillo diducta; anthera una lente aucta.
 5. Stylus, et Stigma, lente aucta.

SPECIFIC CHARACTER.

Heath, with tips two-horned at their base, included within blossoms of an

oblong-ovate form, inflated and smooth; leaves ciliate, growing by fours.

DESCRIPTION.

The Stem shrubby, about half a foot high, cylindrical, thickish, very
much branched, the branches bend downward, then ascend.
Leaves growing by fours, linear, pointed with a recurved base, and an
ascending point, ciliate, flat on their upper, and rolled back on their under,
surface, shining, the leaf-stems very short, and pressed to the branches.
Flowers terminal, numerous, upright, level, and in bunches; the
footstalks purple, having two small opposite floral leaves at their base.
Empalement. Cup four-leaved, erect, keel-shaped, and ciliate.
Blossom of an oblong-ovate form, narrowed toward the top, with a
slightly reflexed border, of a whitish purple, smooth, and shining.
Chives. Eight hair-like threads, nearly of a length with the blossomed,
fixed into the receptacle. Tips within the blossom small, cleft, and two-
horned at their base.
Pointal. Seed-vessel oblong and furrowed. Shaft thread-shaped, of an
equal length with the threads. Summit nearly four-cornered.
Native of the Cape of Good Hope.
In bloom from April till September.

REFERENCE.

1. The Empalement with the Blossom.

2. The Empalement and Floral-leaf magnified.
3. The Chives and Pointal.
4. The Chives detached from the Pointal, one tip magnified.