APPROACH TO PEDIATRIC PULMONARY DISEASES

Dr LEAH GITHINJI PAEDIATRIC

A one year old boy is brought to the emergency room for respiratory distress. He was noted to have cough for about one week prior to consult.

Pediatric History
Respiratory symptoms
dyspnea cough pain wheezing

Pediatric History
Respiratory symptoms
snoring apnea cyanosis

Pediatric History
Respiratory symptoms
chronicity timing during day or night associations with activities such as exercise or food intake

Pediatric History
System Review
cardiac gastrointestinal central nervous hematologic immune systems

Pediatric History
Family History
similar symptoms or any chronic disease with respiratory components

Physical examination
Inspection Palpation Percussion Auscultation

Observation/inspection
Respiratory Rate Presence of grunting Breathing patterns Presence of stridor

Physical Examination

Physical Examination
Observation
Restrictive Disease: shallow breaths Obstructive Disease: slow, deep breaths Extrathoracic: inspiratory stridor intrathoracic: expiratory stridor

 Cut off rate per minute

The most important sign: Tachypnea

Less than 1 week up to 2 months: 60 or more 2 months up to 12 months: 50 or more 12 months up to 5 years: 40 or more.

Pathophysiology:
Hypoxaemia Pulmonary oedema Parenchymal inflammation Restricitve/obstructive diseases

Physical Examination
Percussion
percussion is usually dull in restrictive lung disease and with a pleural effusion, pneumonia, and atelectasis, tympanitic in obstructive disease (asthma, pneumothorax)

Physical Examination
Auscultation
confirms the presence of inspiratory or expiratory prolongation provides information about the symmetry and quality of air movement. detects abnormal or adventitious sounds

Physical Examination
Auscultation
stridor - a predominant inspiratory monophonic noise-cant be heard on naked ear crackles - high pitch, interrupted sounds found during inspiration and more rarely during early expiration, which denote opening of previously closed air spaces

Physical Examination
Auscultation

wheezes - musical, continuous sounds usually caused by the development of turbulent flow in narrow airways

Physical Examination
Digital clubbing sign of chronic hypoxia but may be due to nonpulmonary etiologies Measured by phalangeal depth ratio, hyponichial angle and Schamroths sign

Diagnostic Tests
Arterial blood gas the single most useful rapid test of pulmonary function overall assessment of the functional state of the respiratory system and clues about the pathogenesis of the disease

Diagnostic Tests
CHEST ROENTGENOGRAMS posteroanterior /AP and a lateral view (upright and in full inspiration) If pleural fluid is suspected, decubitus films are indicated.

Diagnostic Tests
UPPER AIRWAY FILM
upper airway obstruction and particularly about the condition of the retropharyngeal, supraglottic, and subglottic spaces

Diagnostic Tests
SINUS AND NASAL FILMS uncertain use Imaging studies are not necessary to confirm the diagnosis of sinusitis in children <6 yr. CT scans are indicated if surgery is required in sinus infections

Diagnostic Tests
CHEST CT AND MRI CT delineates the internal structure of the thorax in much greater detail
MRI is an excellent procedure to delineate hilar and vascular anatomy

Diagnostic Tests
Fluoroscopy
evaluating stridor and abnormal movement of the diaphragm or mediastinum Aid in needle aspiration or biopsy of a peripheral lesion

Diagnostic Tests
BARIUM SWALLOW
recurrent pneumonia persistent cough of undetermined cause stridor persistent wheezing gastroesophageal reflux

Diagnostic Tests
BRONCHOGRAPHY
Diagnosis of suspected bronchiectasis or airway anomalies instilling contrast material directly into the airway CT and MRI have largely replaced bronchography

Diagnostic Tests
PULMONARY ARTERIOGRAPHY AND AORTOGRAMS
evaluation of the pulmonary vasculature vascular rings and suspected pulmonary sequestration Replaced by Real-time and Doppler echocardiography and thoracic CT with contrast

Diagnostic Tests
RADIONUCLIDE LUNG SCANS
evaluating pulmonary embolism and congenital cardiovascular and pulmonary defects replaced by spiral reconstruction CT with contrast medium enhancement

Diagnostic Tests
PULMONARY FUNCTION TESTING
define the type of process (obstruction, restriction) define the degree of functional impairment Used in following the course and treatment of disease

Diagnostic Tests
PULMONARY FUNCTION TESTING
Used in estimating the prognosis of disease preoperative evaluation and in confirmation of functional impairment in patients having subjective complaints but a normal physical examination

Diagnostic Tests
PULMONARY FUNCTION TESTING
plethysmography spirometry diffusing capacity for carbon monoxide (DLCO)

Restrictive lung disease

decrease total lung capacity(TLC )
decreases vital capacity

Obstructive lung disease

increase residual volume and FRC

produce gas trapping

MICROBIOLOGY: EXAMINATION OF LUNG SECRETIONS

Nasopharyngeal or throat cultures by nasotracheal aspiration by transtracheal aspiration through the cricothyroid membrane

MICROBIOLOGY: EXAMINATION OF LUNG SECRETIONS

by a sterile catheter inserted into the trachea either during direct laryngoscopy or through an endotracheal tube

MICROBIOLOGY: EXAMINATION OF LUNG SECRETIONS Sputum specimen

presence of alveolar macrophages (large, mononuclear cells) is the hallmark of tracheobronchial secretions.

MICROBIOLOGY: EXAMINATION OF LUNG SECRETIONS Sputum specimen nasopharyngeal and tracheobronchial secretions : ciliated epithelial cells
Nasopharyngeal and oral secretions : squamous epithelial cells

MICROBIOLOGY: EXAMINATION OF LUNG SECRETIONS Gastric aspirate

suitable for culture for acid-fast bacilli During sleep, mucociliary transport continually brings tracheobronchial secretions to the pharynx, where they are swallowed

MICROBIOLOGY: EXAMINATION OF LUNG SECRETIONS Wright-stained smear of sputum or bronchoalveolar lavage (BAL) fluid
bacterial : PMN leukocytes allergic disease : Eosinophils viral : intranuclear or cytoplasmic inclusion bodies

fungal : Gram or silver stains

EXERCISE TESTING
for detecting diffusion impairment

assessment of the patient's exercise tolerance

SLEEP STUDIES
Polysomnographic studies Diagnosis of obstructive sleep apnea or hypoventilation during sleep Diagnosis of disorders of respiratory control

LUNG VISUALIZATION AND LUNG SPECIMENBASED DIAGNOSTIC TESTS

LARYNGOSCOPY
performed with either a rigid or a flexible instrument evaluation of stridor, problems with vocalization, and other upper airway abnormalities

BRONCHOSCOPY AND BRONCHEOALVEOLAR LAVAGE (BAL) Bronchoscopy :inspection of the airways BAL :used to obtain a representative specimen of fluid and secretions from the lower respiratory tract

Indications for diagnostic bronchoscopy and BAL

recurrent or persistent pneumonia atelectasis unexplained or localized and persistent wheeze the suspected presence of a foreign body hemoptysis

Indications for diagnostic bronchoscopy and BAL

suspected congenital anomalies mass lesions interstitial disease pneumonia in the immunocompromised host

Indications for therapeutic bronchoscopy and BAL

bronchial obstruction by mass lesions foreign bodies or mucous plugs general bronchial toilet bronchopulmonary lavage

Rigid bronchoscopy
ventilation is accomplished through the scope for the extraction of foreign bodies, for the removal of tissue masses, and in patients with massive hemoptysis

Flexible bronchoscopy
ventilation around the flexible scope

can be passed through endotracheal or tracheostomy tubes

Flexible bronchoscopy
can be introduced into bronchi that come off the airway at acute angles can be safely and effectively inserted with topical anesthesia and conscious sedation

Complications
related to sedation transient hypoxemia laryngospasm Bronchospasm cardiac arrhythmias

Complications
Iatrogenic infection bleeding pneumothorax pneumomediastinum

THORACOSCOPY
pleural cavity can be examined thoracoscope is inserted through an intercostal space lung is partially deflated allows the operator to view the surface of the lung, the pleural surface of the mediastinum diaphragm and parietal pleura

THORACOSCOPY
Indications: endoscopic lung biopsy pleural biopsy bleb resection pleural abrasion ligation of vascular rings

THORACENTESIS
For diagnostic or therapeutic purposes fluid is removed from the pleural space by needle

THORACENTESIS
Complications include infection pneumothorax bleeding

Transudates vs. Exudates

Transudates
result from mechanical factors influencing the rate of formation or reabsorption of pleural fluid and generally require no further diagnostic evaluation

Transudates vs. Exudates

Exudates
result from inflammation or other disease of the pleural surface and underlying lung and require a more complete diagnostic evaluation

PERCUTANEOUS LUNG TAP

most direct method of obtaining bacteriologic specimens from the pulmonary parenchyma only technique other than open lung biopsy not associated with at least some risk of contamination by oral flora

PERCUTANEOUS LUNG TAP

Major indications for a lung tap

roentgenographic infiltrates of undetermined cause those unresponsive to therapy in immunosuppressed patients who are susceptible to unusual organisms

LUNG BIOPSY
only way to establish a diagnosis, especially in protracted, noninfectious disease
thoracoscopic or open surgical biopsies

Thank you