upper respiratory tract
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Upper respiratory tract
Lower respiratory tract
Cricoid cartilage
Common diseases
Upper respiratory tract:
♥ Influenza
♥ Tonsillitis
♥ laryngitis
Lower respiratory tract:
♥ bronchitis
♥ Asthma
♥ Pneumonia
Ventilation and perfusion
Alveolar space
70% 100%
O2 CO2
Ventilation and perfusion
Pathophysiology
toxin
Ventilation disorder
Mucous inflammatoryexudation
Tract stenosis andobstruction
Microorganisms
Mucous congestionand edema
EmphysemaPulmonary atelectasis
Gas Exchange disorder
Respiratory failureCirculatory disorder
Neural disorderDigestive disorder
HypoxemiaCO2 elimination disorder
toxemia
According to WHO’s report:
Among all the pediatric patients, 90% suffered
from infectious diseases;
Among all these patients with infectious
diseases, 90% are diagnosed as URI.
Among all these URI patients, 90% are infected
by virus.
Pneumonia
Pneumonia is termed as infections of the
alveoli caused by microorganisms or other
noninfectious factors.
Pneumonia still carries a high mortality rate
in infants who are not treated promptly and
properly.
There are many different causes of pneumonia in
children. The most common causes are germs.
Viruses are usually the cause in 90% of pneumonia
infants and young children. Children with a viral
pneumonia may have a better chance of developing
a bacterial pneumonia, too.
Pneumonia can also be caused by foreign
material such as food or stomach acid, especially in
newborn and infants. These materials are aspirated
(inhaled) into the lungs.
Common causes
Newborns group B Streptococcus
respiratory syncytial virus
Infants
Viruses
parainfluenza viruses, influenza virus, adenovirus
Atypical organisms
Chlamydia trachomatis, Pneumocystis carinii
Bacterial
B. pertussis, Streptococcus pneumoniae, Haemo-
philus influenzae
Common causes
Young children
Viruses
parainfluenza viruses, influenza virus, adenovirus
Atypical organisms
Mycoplasma pneumoniae
Bacterial
Pneumococcus, mycobaterial tuberculosis
Older children and adolescents
Atypical organisms
Mycoplasma pneumoniae, Chlamydia
trachomatis
Bacterial
Pneumococcus, B. pertussis, mycobaterial
tuberculosis
Bacterial pneumonia
Viral pneumonia
Mycoplasmal pneumonia
Common Signs and symptoms
Cough
Breathing pattern
Cyanosis
Respiratory Sound
Cough
A cough is a voluntary or involuntary
explosive expiration. The cough reflex is initiated
by the stimulation of subepithelial
mechanoreceptors in the trachea,
bronchi and interstitium.
Cough
Paroxysm: A series of coughs that is difficult to stop. It is due
to pertussis, viral infection and asthma, etc. During paroxysm
of coughing, headache, vomitting, conjuctival hemorrhage may
be induced by the increased intracranial pressure.
An acute cough may be benefit to eliminate the obstruction or
facilitate mucociliary clearance when foreign bodies or excess
mucus is present. A chronic cough may be harmful to cause
complications, such as chest pain.
Breathing pattern
Normal breath breath with Severe pneumonia
Cyanosis
When maximal respiratory efforts cannot provide
sufficient ventilation to saturate the blood fully and
the amount of unoxygenated Hb exceeds 50g/L, the
children will appear cyanotic.
Respiratory sounds
Breath sounds are influenced by the depth of
breathing, velocity of the air flow, position of the
patients and the fluid in the air space.
The pitch of breath sounds depends on the size of
the orifices or the diameter of the airway: the smaller
the orifice or the airway, the higher the pitch.
Symptoms of different pneumonia
Viral pneumonia
The respiratory syncytial virus is the most common agent.
It is often accompanied by a skin rash and unresponsive to
antibiotics.
Adenovirus may produce viral pneumonia in children and
young adults. It more commonly causes upper respiratory
tract disease with prominent rhinitis.
RSV Pneumonia
Respiratory syncytial virus is the major respiratory
pathogen of young children, causing lower respiratory
tract disease in infants. Infection may occur at any
time but is least frequent in the summer, accounting
for 20 to 25% of hospital admissions for pneumonia of
young infants and children.
RSV Pneumonia
lower respiratory diseases, primarily, pneumonia,
bronchiolitis and tracheobronchitis occurs in 25-40%
of cases
onset is gradual with rhinorrhoea, low-grade fever,
cough, wheezing and mild systemic symptoms
tachypnoea, dyspnoea, frank hypoxia, cyanosis and
apnoea may develop in severe cases
wheezing and crackles may be heard on auscultation
there may be an accompanying skin rash
Bacterial Pneumonia
usually a history of preceding upper respiratory tract viral
infection.
more common in winter months with sudden onset
marked fever; febrile convulsions in preschool children
cough - initially dry but replaced by a productive cough with
rusty-coloured sputum after 24 - 48 hours
breathing - rapid and shallow; diminished movement on the
affected side
may be signs of consolidation and a friction rub
pneumococcal pneumonia
Bacterial Pneumonia
usually a history of preceding upper respiratory tract viral
infection.
more common in winter months with sudden onset
marked fever; febrile convulsions in preschool children
cough - initially dry but replaced by a productive cough with
rusty-coloured sputum after 24 - 48 hours
breathing - rapid and shallow; diminished movement on the
affected side
may be signs of consolidation and a friction rub
staphylococcal pneumonia
Mycoplasmal pneumonia
peak rate of infection in autumn and early winter
initial influenza-like disease with headache, fever,
malaise, myalgia, diarrhea and fatigue - often
develop several days before the onset of
respiratory problems; the malaise and fatigue may
persist for long after the acute illness
wide variety of respiratory and non-respiratory
complications
cough - initially dry and often insignificant; usually
becomes productive with a mucoid and purulent
sputum; often paroxysmal, disturbing sleep; may be
absent in one-third of cases
isolated crackles or areas of wheezing may be
heard over one of the lower lobes
subsegmental atelectasis and small effusions often
detectable in the absence of prominent chest
symptoms
Radiology
Radiologic features are variable depending upon the extent
of the infection. Chest radiology
may show hyperexpansion,
peribronchial thickening, and
infiltrates ranging from diffuse
interstitial infiltrates to
segmental or lobar consolidation.
RSV pneumonia
pneumococcal pneumonia
classically, shows consolidation with a lobular
distribution note that radiological
changes may lag behind
the clinical course of the
disease and conversely,
radiologic features may
persist for several weeks
after being cured.
staphylococcal pneumonia
The chest radiograph often appears cavitated.
Infection starts in the
bronchi, causing areas
of patchy consolidation
in one or more lobes.
These break down to
form multiple thin walled
abscesses – pneumatocoeles
- which appear as cysts.
Mycoplasma pneumoniae
Chest radiology is highly variable. The most frequent pattern is one
of bronchial thickening
with areas of interstitial
infiltration and subsegmental
atelectasis involving one of
the lower lobes; sometimes,
there may be dramatic
shadowing in both lower lobes.
Often there is no correlation
between radiologic appearance
and the clinical state of the patient.
Lab tests
RSV pneumonia
Diagnosis is established by
isolation of RSV from respiratory
secretions, particularly, sputum or
throat swabs. Immunologic
reactions such as ELISA are then
used to detect the virus in tissue
culture.
Techniques based on complement fixation or
neutralisation of antibody titers are more valuable
in older children and adults.
A bedside immunoassay kit is now available
which detects RSV; confirmation should be sought
with the laboratory tests detailed above.
Lab tests
pneumococcal pneumonia
white cells - raised; often greater than 15 x 109
per litre
ESR - raised; may exceed 100 mm in an hour
CRP - raised
Sputum examination, sputum and blood culture-
positive in 25-40% of cases, are essential in
management of a patient with pneumonia. It may
possible to demonstrate
pneumococcal antigen
in both blood and sputum.
Lab tests
staphylococcal pneumonia
sputum examination and culture
blood culture - positive in 20 - 30% of cases
full blood count
ESR
CRP
Lab tests
Mycoplasma pneumoniae
White cell count is usually normal but ESR may be
raised and C reactive proteins may be elevated.
a rise of specific antibody titre - occurs in most
instances, but, obviously, requires paired samples
separated by a week or more, and is therefore not
useful in the inital diagnosis
cold haemagglutination serology - present in about
50% of cases but may produce false positives in
measles, infectious mononucleosis,
adenovirus pneumonias, certain
tropical diseases and collagen
vascular disease.
Treatment is largely symptomatic. Intubation and ventilatory
assistance are given if there is severe hypoxia. Humidified
oxygen may be required if arterial oxygen tension is low.
Ribavarin, a nucleoside analogue which is active in vitro
against RSV, has been shown to relieve lower respiratory tract
illness in children. It is used by inhalation since oral
administration is associated with liver and bone marrow toxicity.
Studies have yet to be conducted in adults.
RSV pneumonia
pneumococcal pneumonia
Pneumococcal pneumonia is generally treated with
amoxycillin, ampicillin or co-amoxiclav.
For severe infections:
intravenous antibiotics e.g. ampicillin or co-amoxiclav.
Oral amoxycillin or augmentin can be used when the
pneumonia is resolving clinically and the patient is
apyrexial.
For mild-moderate infections:
amoxycillin 500mg tids for 10-14 days.
Alternative treatments in penicillin allergy include
erythromycin or cefuroxime (but note 10% cross-
sensitivity).
Prophylaxis:
pneumococcal vaccination
staphylococcal pneumonia
Antibiotic treatment should be started after blood and sputum has been taken for culture. Initial therapy is often blind.
Consult with a bacteriologist about appropriate drug treatment if in doubt:
penicillin-sensitive first choice: benzylpenicillin
alternative: erythromycin
penicillinase producing first choice: flucloxacillin
alternative: dependent on local sensitivities
Mycoplasma pneumoniae
Treatment is with either erythromycin or tetracycline:
erythromycin or other macrolide e.g. clarithromycin or
azithromycin:
tetracycline:
an alternative to erythromycin for the treatment of chlamydial
and mycoplasma infections
Treatment period is for a minimum of 10-14 days.
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