You are on page 1of 129

Pediatric Respiratory Physiology

TOPIC OUTLINE
I. Anatomy and physiology of the respiratory tract
II. Common respiratory problems in children
A. Infectious disorders
1. acute upper respiratory infections
» rhinitis
» sinusitis
» otitis externa/media
» acute tonsillopharyngitis
2. acute laryngitis
3. bronchitis
4. bronchiolitis
5. pneumonias

Course Content: (cont.)
B. Non-infectious disorders
• foreign bodies
• atelectasis
• Asthma

C. Pulmonary tuberculosis
– primary infection
– progressive primary infection
– multidrug resistant pulmonary tuberculosis
– miliary tuberculosis

Fetal Lung Development • embryonic • 7-16 weeks: formation of the bronchial tree • 17-24 weeks: primitive gas exchange surface forms • 24-40 weeks: alveolar development continues • 35 weeks: stable surfactant production .

5 Stages of LUNG development • EMBRYONIC: week 4 .8 years .5 • PSEUDOGLANDULAR: week 5 – 16 • CANALICULAR: week 16 – 25 • SACCULAR: week 24 – 40 • ALVEOLAR: late fetal .

glandular extensive airway branching Terminal bronchioles . STAGES OF LUNG DEVELOPMENT Stage Human Features lung buds originate as an outgrowth from the ventral Embryonic week 4 to 5 wall of the foregut where lobar division occurs conducting epithelial tubes surrounded by thick Pseudo week 5 to 17 mesenchyme are formed.

late fetal to 8 marked increase of the Alveolar years number and size of capillaries and alveoli . Stage Human Features Respiratory bronchioles are produced. increasing number of capillaries in close contact Canalicular week 16 to 25 with cuboidal epithelium and the beginning of alveolar epithelium development (Type I and II) alveolar ducts and air sacs are Saccular week 24 to 40 developed. Surfactant synthesis secondary septation occurs.

.

Postnatal Lung Development • Newborn – Airway branching complete – Alveolar formation is not complete Age 1-10 years: number of alveoli increase Age 10 to young adult: lung grows larger with little alveolar growth .

Anatomical and physiological differences between adults and children • As children grow. • narrowest point in the airway is below the cords for children. • The pediatric airway overall has poorly developed cartilaginous integrity allowing for more laxity throughout the airway. the airway enlarges and moves more caudally as the cervical spine elongates. .

Anatomical and physiological differences between adults and children • The magnitude of these differences relate to age • largest variation: in neonates and infants • The older child increasingly approximates to adult parameters .

ANATOMICAL differences in the airway • Compared to the adult. in the child: – obligate nasal breathers – ribs are oriented much more horizontally and rib cage is much softer – large tongue – Narrower at all levels – larynx is smaller and is in a higher position and more anterior .

LARYNX • High position • Infant : C 1 • 6 months: C 3 • Adult: C 5-6 .

the narrowest part of the upper airway is the cricoid ring – Tracheal cartilage is softer and smaller in both length and diameter . in the child: – epiglottis is longer. ANATOMICAL differences in the airway • Compared to the adult. – in the younger child. floppy and U-shaped .

moves less efficiently and contains fewer fatigue-resistant muscle fibers • Infants and young children rely on diaphragm to breathe more than adults do . ANATOMICAL differences in the airway • diaphragm is flatter and less domed.

MUSCLE FIBERS • Type I fibers – slow-twitch and high-oxidative in nature – Low contractility but are fatigue resistant • Type II fibers – fast-twitch and low-oxidative – have high contractility but are more prone to fatigue. .

– Respiratory muscles of premature babies and young infants are therefore more susceptible to fatigue. resulting in earlier decompensation. – This increases to around 25% in full- term newborns and around 50% in children >2 years. .– The proportion of type I fibers in the diaphragm and intercostals of premature infants is only around 10%.

• Overall. has poorly developed cartilaginous integrity allowing for more laxity throughout the airway. . the pediatric airway being smaller.

ANATOMY PEDIATRIC ADULT Tongue Large Normal Epiglottis shape Floppy. omega Firm.C4 Level of C5 – C6 Larynx shape Funnel shaped Column Larynx position Angles posteriorly Straight up and away from the down glottis Narrowest point Subglottic region At level of vocal cords Lung volume 250 ml at birth 6000 ml as adult . flatter shaped Epiglottis level Level C3 .

consuming relatively more oxygen. “sucks in” the floppy airway → decreases airway diameter → increases the work of breathing • The work of breathing is higher in children. PHYSIOLOGICAL differences in breathing between adults and children • Compliant chest wall → creates a greater negative inspiratory pressure . .

? Remember: Lung volumes and capacities .

• Inspiratory capacity (IC) is the amount of air inspired by maximum inspiratory effort after tidal expiration.• Tidal volume (VT) is the amount of air moved in and out of the lungs during each breath. tidal volume is normally 6-7 mL/kg body weight. • Expiratory reserve volume (ERV) is the amount of air exhaled by maximum expiratory effort after tidal expiration . at rest.

The volume of gas remaining in the lungs after maximum expiration • Vital capacity (VC) .defined as the amount of air moved in and out of the lungs with maximum inspiration and expiration. • Total lung capacity (TLC) .• Residual volume (RV) .is the volume of gas occupying the lungs after maximum inhalation. .

Dynamic volumes • Maximum forced expiratory flow (FEF max) is generated in the early part of exhalation – commonly used indicator of airway obstruction in asthma and other obstructive lesions – a decrease in flow is a reflection of increased airway resistance .

the total volume exhaled during this maneuver • FEV1 .• Forced vital capacity (FVC) .volume exhaled in one second • FEV1/FVC is expressed as a percentage of FVC .

• Chest wall compliance is a major determinant of FRC. thereby decreasing FRC . • The increased chest wall compliance in infants allows greater chest wall retraction because of less opposition to the lung recoil.

and therefore proportionally smaller oxygen reserves . Infants and children… • Tidal volume is proportionally smaller to that of adolescents and adults • Metabolic oxygen requirements of infants and children are about double those of adolescents and adults • Children have proportionally smaller functional residual capacity.

PULMONARY SIGNS & SYMPTOMS .

A child who appears in respiratory distress might not have a respiratory illness • abnormalities of central nervous system (encephalitis) • neuromuscular disease such as Guillain- Barre syndrome or myasthenia gravis and those with an abnormal respiratory drive • metabolic acidosis (diabetic ketoacidosis) .

Respiratory Distress: S/S • diagnosed from signs such as: – cyanosis – nasal flaring – grunting – tachypnea – wheezing – chest wall retractions – stridor .

Tachypnea • Less than 3 months: > 60 breaths per minute • 3 months .12 months: > 50 breaths per minute • 1 year – 4 years: > 40 breaths per minute .

AIRWAY : 3 anatomic parts • extrathoracic airway – from the nose to the thoracic inlet • intrathoracic-extrapulmonary airway – from the thoracic inlet to the main stem bronchi • intrapulmonary airway – within the lung parenchyma .

valuable signs in localizing the site of respiratory pathology • rate and depth of respiration • retractions • stridor • Wheezing • grunting .

intercostal.suprasternal) – With increased negative intrathoracic pressure during inspiration . AIRWAY : 3 anatomic parts • extrathoracic airway – Hallmark: Inspiratory stridor – retractions (chest wall.

high-pitched respiratory sound • usually inspiratory but can be biphasic and is produced by turbulent airflow • it is not a diagnosis but a sign of upper airway obstruction . Stridor • is a harsh.

• Intrathoracic-extrapulmonary airway – Hallmark: Expiratory wheezing • Intrapulmonary airway – Rapid and shallow respirations (tachypnea) – Grunting .

such as in pulmonary edema. hyaline membrane disease. GRUNT • is produced by expiration against a partially closed glottis • is an attempt to maintain positive airway pressure during expiration • most beneficial in alveolar diseases that produce widespread loss of FRC. and pneumonia .

INTERPRETING THE CLINICAL SIGNS OF RESPIRATORY DISEASE EXTRA-THORACIC INTRATHORACIC. INTRA-PULMONARY EXTRA SIGN AIRWAY PULMONARY AIRWAY AIRWAY OBSTRUCTION OBSTRUCTION OBSTRUCTION Tachypnea + + +++ Retractions ++++ ++ ++ Stridor ++++ ++ − Wheezing ? +++ ++ Grunting ? ? +++ .

DIAGNOSTIC PROCEDURES • CBC – not very reliable • Cultures – if (+) exudates • Chest radiographs – In infants and young children ( AP-Lateral views) • Why? Lesions in the hilar areas maybe obscured by the cardiac silhouette • ABG .

RESPIRATORY DISORDERS .

RHINITIS • is a viral illness • prominent symptoms: – rhinorrhea (nasal discharge) – nasal obstruction .

E. limited to the upper respiratory tract • A change in color or consistency of the secretions is common during the course of illness and is NOT indicative of sinusitis or bacterial superinfection . Common cold • P.

.• A green or yellow nasal discharge should not be construed as evidence of secondary bacterial infection (neutrophils cause yellow-green discoloration because of their natural myeloperoxidase activity).

FORMS OF RHINITIS
allergic rhinitis nonallergic
(hay fever) rhinitis
(common cold)
• pollen
• dust mites • RHINOVIRUSES
• mold • Adenoviruses
• animal • RSV
dander • Coxsackie’s viruses

RHINITIS

• common in children under 5 years of age.

• Most children will develop three to eight colds
or respiratory illnesses a year. This number
may even be higher in children who attend
day care or are exposed to tobacco smoke.

Epidemiology

• Mode of transmission:
– by aerosols
• Small particle (Influenza virus)
• Large particle
– direct contact (Rhinoviruses and RSV)

• Rhinoviruses remain viable on skin and also on
objects (fomites) for at least 2 hours.

Clinical manifestations: • Fever +/- • rhinorrhea • sore throat 50% – 1ST symptom to appear – cough – similar cases in the family .

RHINORRHEA CONDITION DIFFERENTIATING FEATURES Prominent itching and sneezing Allergic rhinitis Nasal eosinophils Unilateral. foul-smelling secretions Foreign body Bloody nasal secretions Presence of fever. headache or facial pain. Sinusitis or periorbital edema or persistence of rhinorrhea or cough for >14 days Mucopurulent nasal discharge that Streptococcosis excoriates the nares Pertussis Onset of persistent or severe cough Persistent rhinorrhea with onset in the 1st Congenital syphilis 3 months of life .

Treatment (Symptomatic) : fever antipyretics nasal obstruction saline nasal drops/solution rhinorrhea antihistamines .

• Exacerbation of asthma . or facial swelling develop. facial pain. Complications: • Otitis media – most common • Bacterial sinusitis – should be considered if rhinorrhea or daytime cough persists without improvement for at least 10-14 days or if signs of more-severe sinus involvement such as fever.

. • Vitamin C and echinacea DO NOT prevent the common cold. • Prevention of the spread of viruses by direct contact can be most readily accomplished by good hand washing by the infected individual and/or the susceptible contact. PREVENTION • Chemoprophylaxis or immunoprophylaxis is generally not available for the common cold. • Interrupting the chain involved in the spread of virus by direct contact may prevent colds.

SINUSITIS • Acute inflammation of the mucosa of one or more of the paranasal sinuses • Generally follows rhinitis • 2 types: viral and bacterial .

• Both the ethmoidal and maxillary sinuses are present at birth. but only the ethmoidal sinuses are pneumatized • maxillary sinuses are not pneumatized until 4 yr of age • sphenoidal sinuses are present by 5 yr of age • frontal sinuses begin development at age 7-8 yr and are not completely developed until adolescence. .

and cigarette smoke exposure . allergic rhinitis. SINUSITIS • Can occur at any age • Predisposing conditions include viral upper respiratory tract infections (associated with out-of-home daycare or a school-aged sibling).

SINUSITIS • Etiology: Streptococcus pneumoniae (∼30%) • Pathogenesis: typically follows a viral upper respiratory tract infection .

including nasal congestion. purulent nasal discharge (unilateral or bilateral). fever. and cough • PE: erythema and swelling of the nasal mucosa with purulent nasal discharge . SINUSITIS: signs and symptoms • nonspecific complaints.

or severe respiratory symptoms. including temperature of at least 39°C and purulent nasal discharge for 3-4 consecutive days . including nasal discharge and cough. for >10-14 days without improvement. Diagnosis • Based on history • Persistent symptoms of upper respiratory tract infection.

TREATMENT • although 50-60% of children with acute bacterial sinusitis recover without antimicrobial therapy • For uncomplicated: Amoxicillin .

cefpodoxime. daycare attendance. or age <2 yr for the presence of resistant bacterial species – for children who fail to respond to initial therapy with amoxicillin within 72 hr – Rx: high-dose amoxicillin-clavulanate (80-90 mg/kg/day of amoxicillin) . clarithromycin. cefuroxime axetil. TREATMENT • For penicillin-allergic patients: trimethoprim- sulfamethoxazole. or azithromycin • For children with risk factors – antibiotic treatment in the preceding 1-3 mo.

Sinusitis .Complications • Eye complications: – peri-orbital/ orbital cellulitis • Intracranial complications: – Meningitis – cavernous sinus thrombosis – Abscess – Subdural empyema .

OTITIS EXTERNA • Precipitating factors. – Trauma – Swimming – Impacted cerumen – Change from the normal acid to alkaline pH of the external auditory canal .

E. OTITIS EXTERNA • Etiology: Staph aureus (most common) Others: gram negative bacilli (Pseudomonas aeruginosa. Proteus vulgaris. coli) • s/s: ear pain aggravated by movement of the tragus hearing is normal .

TREATMENT • Cleansing and drying of External Auditory Canal • If (+) infection: DO NOT irrigate • If (+) cellulitis and chondritis: Rx antibiotic – OXACILLIN or any penicillinase-resistant penicillin .

mastoid antrum and mastoid air cell system . tympanic cavity. OTITIS MEDIA • Inflammation of the mucoperiosteal lining of the eustachian tube.

OTITIS MEDIA • Peak incidence: 1st 2 yrs • Three pathogens predominate in OM: Streptococcus pneumoniae (most common) Haemophilus influenzae Moraxella catarrhalis .

wide. Predisposing factors of developing otitis media in children: • developmental alterations of the Eustachian tube (short. & straight) • an immature immune system • frequent infections of the upper respiratory mucosa • the usual lying-down position of infants favors the pooling of fluids. such as formula. .

.

.

evidence of ear pain may be manifested by irritability or a change in sleeping or eating habits and occasionally. holding or tugging at the ear . • In young children. especially in infants and young children.• Symptoms of AOM are variable.

• Diagnosis: confirmed by otoscopy (TM) – Findings: injection of TM absent light reflex decreased motility retraction or bulging of TM .

. Otitis media • Acute Otitis media with HEALTHY TYMPANIC MEMBRANE purulent effusion behind a bulging tympanic membrane.

15mg/kg/24hrs 1-15 years Trimethoprim- sulfamethoxazole . 10- 20mg/kg/24hrs in 2 12 hourly doses . Treatment AGE GROUP EMPIRIC THERAPY Neonates Ampicillin . 200mg/kg/24hrs parenteral in 4-6 hrly doses Amikacin.

Otitis media • Tympanostomy tube in place Chronic OM .

ACUTE PHARYNGITIS • Sore throat .

B) Bacterial: Group A beta hemolytic streptococcus (GABHS) Early detection can prevent complications like acute rheumatic fever and post streptococcal GN. . Symptoms usually last for 3-5 days. Pharyngitis: Etiology A) Viral: Most common Rhinovirus (most common).

Pathogenesis • Colonization of the pharynx by GABHS can result in either asymptomatic carriage or acute infection. • The M protein is the major virulence factor of GABHS and facilitates resistance to phagocytosis by polymorphonuclear neutrophils .

Pharyngitis: signs and symptoms • Rapid onset • absence of Cough • Fever • Sore throat • Malaise • Rhinorrhoea .

cervical lymphadenopathy .• Classic triad of GABHS: High fever tonsillar exhudates ant.

Streptococcal pharyngitis • Physical examination: – red pharynx – enlarged tonsils with yellow blood- tinged exudate – petechiae on the soft palate and posterior pharynx – enlarged/tender anterior cervical lymph nodes .

Streptococcal pharyngitis .

Pharyngitis: Treatment • early antibiotic therapy hastens clinical recovery by 12-24 hr • RX: penicillin • amoxicillin .

Strep. pharyngitis • Prevention of acute rheumatic fever is successful if treatment started within 9 days of illness • Clindamycin (20mg/k/day) - recommended for carriers .

Needed only when suspicion is high and rapid strep is negative . anterior cervical lymphadenopathy • Rapid strep: Throat swab.Not required usually. Throat culture . Sensitivity of 80% and specificity of 95%. DIAGNOSIS • PE: Tonsillar exudates.

and later nonsuppurative illnesses. such as parapharyngeal abscess. such as acute rheumatic fever and acute postinfectious glomerulonephritis . Complications • include : – local suppurative complications.

 Viral or bacterial . ACUTE TONSILLITIS Etiology  Tonsillitis often occurs with Pharyngitis.

and the uvula may be red. stippled. and swollen . blood-tinged exudate • There may be petechiae or “doughnut” lesions on the soft palate and posterior pharynx. ACUTE TONSILLOPHARYNGITIS • The pharynx is red • tonsils are enlarged and classically covered with a yellow.

cool-mist humidification and throat lozenges B) Antibiotics: a) Benzathine Pn-G 1. .2 million units IM x 1OR Pn V orally for 10 days b) For Pn allergic pts: Erythromycin 500mg QID x 10 days OR Azithro 500 mg OD x 3 days. analgesics. ATP : Treatment A) Symptomatic: Saline gargles.

Epiglottitis. Acute Inflammatory Upper Airway Obstruction (Croup. Laryngitis. and Bacterial Tracheitis) .

r – radius • minor reductions in cross-sectional area due to mucosal edema or other inflammatory processes cause an exponential increase in airway resistance and a significant increase in the work of breathing. l – length.• The lumen of an infant's or child's airway is narrow • airway resistance is inversely proportional to the 4th power of the radius R ~ 8l / r4 R – resistance. .

CROUP (Laryngotracheobronchitis) • Viral infection (parainfluenza) • Affects larynx. Air flow obstruction • Incidence: 6 months to 4 years Males > Females . trachea • Subglottic edema.

Croup: Signs/Symptoms • Low grade fever • “Cold” progressing to hoarseness • “barking” cough • Inspiratory stridor .

cool air • Severe Croup – Humidified high concentration oxygen – Nebulized racemic epinephrine – Anticipate need to intubate. assist ventilations . Croup: Management • Mild Croup – Reassurance – Moist.

EPIGLOTTITIS • Bacterial infection (Hemophilus influenza) • Affects epiglottis. adjacent pharyngeal tissue • Supraglottic edema Complete Airway Obstruction .

Epiglottitis: Incidence • Incidence: Children > 4 years old Common in ages 4 .7 • Pedia incidence falling due to HiB vaccination • Can occur in adults. particularly elderly .

extends neck slightly • One-third present unconscious. in shock . leans forward. severe distress in hours • High fever • Intense sore throat. Epiglottitis: Signs/Symptoms • Rapid onset. difficulty swallowing • Drooling • Stridor • Sits up.

Epiglottitis Respiratory distress+ Sore throat+Drooling = Epiglottitis .

Epiglottitis: Management • High concentration oxygen • Do not attempt to visualize airway .

Epiglottitis Immediate Life Threat Possible Complete Airway Obstruction .

Croup and Epiglottitis
CROUP EPIGLOTTITIS
Age 6 months to 4 years Age 3 to 7 years

Slow onset Rapid onset

Patient may lie or sit upright Patient prefers to sit upright

Barking cough No barking cough, possible
inspiratory stridor

Lack of drooling Drooling, pain during
swallowing

Low-grade fever High fever

Acute Bronchitis
• Inflammation of the bronchial
respiratory mucosa leading to
productive cough.

Acute Bronchitis
• Etiology: A)Viral
B) Bacterial (Bordetella pertussis,
Mycoplasma pneumoniae,
and Chlamydia pneumoniae)
• Diagnosis: Clinical
• S/S: Productive cough, rarely fever or
tachypnea

TREATMENT A) Symptomatic B) If cough persists for more than 10 days: Azithromycin x 5 days OR Clarithromycin x 7 days .

• pneumonia. • asthma. • bronchiectasis .COMPLICATIONS • chronic bronchitis.

and in those who live in crowded conditions. in those who have not been breast-fed. BRONCHIOLITIS • viral disease ( RSV >50% ) • more common in boys. • Incidence: Children < 2 years old 80% of patients < 1 year old .

mucus. and cellular debris and air trapping • ↑ Resistance in the small air passages during both inspiration and exhalation . Bronchiolitis: Pathophysiology • bronchiolar obstruction with edema.

. Bronchiolitis: Pathophysiology • BUT because the radius of an airway is smaller during expiration…… the resultant respiratory obstruction leads to early air trapping and overinflation • If obstruction becomes complete. trapped distal air will be resorbed → develop atelectasis.

Bronchiolitis: Signs/Symptoms

• Infant < 1 year old
• Recent upper respiratory infection exposure
• Gradual onset of respiratory distress
• Expiratory wheezing
• Extreme tachypnea (60 - 100+/min)
• Cyanosis

Bronchiolitis: Management
• Humidified oxygen
• bronchodilators
• Anticipate need to intubate, assist
ventilations

ASTHMA BRONCHIOLITIS
Age >2 years old <2 years old
Fever Normal temp positive
Family history positive Negative
Hx of Allergy Positive Negative
Response to positive negative
Epinephrine

PNEUMONIA • inflammation of the parenchyma of the lungs .

alveolar macrophages . Physiologic Pulmonary Defense mechanisms • mucociliary clearance • the properties of normal secretions such as secretory immunoglobulin A (IgA).

or radiation-induced pneumonitis. . and drug. hypersensitivity reactions. PNEUMONIA • most cases of pneumonia are INFECTIOUS caused by microorganisms (viral and bacterial) • NON-INFECTIOUS causes include aspiration of food or gastric acid. hydrocarbons. foreign bodies. and lipoid substances.

PNEUMONIA • 3 wks – 4yrs: Streptococcus pneumoniae (pneumococcus) • 5 yrs and older: Mycoplasma pneumoniae and Chlamydia .

• Recurrent pneumonia is defined as 2 or more episodes in a single year or 3 or more episodes ever. . with radiographic clearing between occurrences. • An underlying disorder should be considered if a child experiences recurrent pneumonia.

cough and tachypnea • Tachypnea . rhonchi.most consistent clinical manifestation of pneumonia • PE: crackles. decreased breath sounds . Clinical Symptoms of Pneumonia • Triad of fever.

DIAGNOSIS • An infiltrate on chest radiograph supports the diagnosis of pneumonia .

Viral pneumonia • hyperinflation • bilateral interstitial infiltrates • peri-bronchial cuffing .

Bacterial pneumonia .consolidation .

Diagnosis -Pneumonia • Definitive diagnosis .no clinical use .isolation of microorganism • blood culture is positive only in 10-30% of cases • sputum culture .

. • Therapeutic alternatives : cefuroxime axetil and amoxicillin/clavulanate. TREATMENT • For mildly ill children who do not require hospitalization: – amoxicillin is recommended – In communities with a high percentage of penicillin-resistant pneumococci. high doses of amoxicillin (80-90 mg/kg/24 hr) should be prescribed.

pneumoniae : a macrolide antibiotic such as azithromycin • In adolescents: a respiratory fluoroquinolone (levofloxacin) may be considered as an alternative . TREATMENT • For school-aged children and in children in whom infection with M. pneumoniae or C.

When to hospitalize? .

FACTORS SUGGESTING NEED FOR HOSPITALIZATION OF CHILDREN WITH PNEUMONIA • Age <6 months • Sickle cell anemia with acute chest syndrome • Multiple lobe involvement • Immunocompromised state • Toxic appearance • Moderate to severe respiratory distress • Requirement for supplemental oxygen • Dehydration • Vomiting or inability to take oral fluids and medications • No response to appropriate oral antibiotics • Social factors .

S. S.most common causes of parapneumonic effusions and of empyema . pneumonia. aureus . pyogenes . Complication of Pneumonia • Due to direct spread of bacterial infection within the thoracic cavity – Pleural effusion – Empyema – Lung abscess • S.

right .Pleural effusion.

and osteomyelitis are rare complications of hematologic spread of pneumococcal or H. influenzae type b infection. Complication of Pneumonia • result of bacteremia and hematologic spread • Meningitis. . suppurative arthritis.

6 – Pleural fluid LDH > 2/3 upper normal – pH < 7.2 .5 – Pleural fluid/serum LDH > 0. Parapneumonic Effusion • Thoracentesis –diagnostic and therapeutic • Diagnostic: pleural fluid analysis • Usually exudative – Pleural fluid/serum protein >0.

Thank You For Your Attention .

QUESTIONS? .