Respiratory Disorders in ChildrenRespiratory Disorders in Children

Dr Varsha Atul ShahDr Varsha Atul Shah

Respiratory disorders are Respiratory disorders are important asimportant as

They account for 50% of consultations with general They account for 50% of consultations with general practitioners for acute illness in young children and practitioners for acute illness in young children and one-third of consultations in older childrenone-third of consultations in older children

Respiratory illness leads to 20-35% of acute paediatrRespiratory illness leads to 20-35% of acute paediatric admissions to hospitalic admissions to hospital

They are the fifth most common cause of death in chThey are the fifth most common cause of death in children ages between one and 14 years in the UKildren ages between one and 14 years in the UK

Asthma is the most common chronic illness of childAsthma is the most common chronic illness of childhood in the UK and the most frequent single cause fhood in the UK and the most frequent single cause for emergency hospital admissionor emergency hospital admission

Cystic fibrosis is the most common lethal inherited Cystic fibrosis is the most common lethal inherited disorder in Caucasians disorder in Caucasians

Respiratory infectionsRespiratory infections

most frequent infections of childhood. most frequent infections of childhood. The pre-school child has on average 6-8 resThe pre-school child has on average 6-8 res

piratory infections a year. piratory infections a year. Most are mild, self-limiting illness but some,Most are mild, self-limiting illness but some,

such as bronchiolitis or epiglottitis, are pot such as bronchiolitis or epiglottitis, are potentially life-threateningentially life-threatening

PathogensPathogens

Viruses: cause 80-90% of childhood respiratory infections. Viruses: cause 80-90% of childhood respiratory infections. The most important are the respiratory syncycial virus (RSThe most important are the respiratory syncycial virus (RSV), rhinoviruses, parainfluenza, influenza and adenovirus. V), rhinoviruses, parainfluenza, influenza and adenovirus. An individual virus can cause several different patterns of ilAn individual virus can cause several different patterns of illness, e.g. RSV can cause bronchiolitis, croup, pneumonia olness, e.g. RSV can cause bronchiolitis, croup, pneumonia or a common cold. r a common cold.

The important bacterial respiratory pathogens are StreptoThe important bacterial respiratory pathogens are Streptococcus pneumoniae and other streptococci, coccus pneumoniae and other streptococci, Haemophilus iHaemophilus influenzaenfluenzae, , Bordetella pertussisBordetella pertussis which cause whooping cou which cause whooping cough, and gh, and mycoplasma pneumoniaemycoplasma pneumoniae. . Mycobacterium tubercuMycobacterium tuberculosislosis remains an important pathogen. Some pathogens cau remains an important pathogen. Some pathogens cause predictable epidemics, such as RSV bronchiolitis every wse predictable epidemics, such as RSV bronchiolitis every winter, whereas others, e.g. pneumococcus, show little seasinter, whereas others, e.g. pneumococcus, show little seasonal variation.onal variation.

Host and environmental Host and environmental factorsfactors

Poor socio-economic status (such as overcrowded, Poor socio-economic status (such as overcrowded, damp housing and poor nutrition)damp housing and poor nutrition)

Larger family sizeLarger family size Maternal smokingMaternal smoking Boys more than girlsBoys more than girls Prematurity-especially infants who have required aPrematurity-especially infants who have required a

rtificial ventilationrtificial ventilation Congenital abnormalities of the heart or lungsCongenital abnormalities of the heart or lungs Rarely, immune deficiency, either congenital, e.g.aRarely, immune deficiency, either congenital, e.g.a

gmmaglobulinaemia, or acquired, e.g. malignant dgmmaglobulinaemia, or acquired, e.g. malignant disease or HIV infection.isease or HIV infection.

The child’s ageThe child’s age

The child’s age influences the prevalence The child’s age influences the prevalence and severity of infections. and severity of infections.

It is in infancy that serious respiratory It is in infancy that serious respiratory illness requiring hospital admission is the illness requiring hospital admission is the most common and the risk of death is most common and the risk of death is great. great.

There is an increased frequency of There is an increased frequency of infections when the child or older siblings infections when the child or older siblings start nursery or school. Repeated upper start nursery or school. Repeated upper respiratory tract infections are rarely an respiratory tract infections are rarely an indication of underlying disease indication of underlying disease

Classification of Classification of respiratory infectionsrespiratory infections

Upper respiratory tract infectionUpper respiratory tract infectionLaryngeal/tracheal infectionLaryngeal/tracheal infectionBronchitisBronchitisBrochiolitisBrochiolitisPneumonia Pneumonia

Upper respiratory tract Upper respiratory tract infection (URTI)infection (URTI)

80% of respiratory infections involve onl80% of respiratory infections involve only the nose, throat, ears and sinusesy the nose, throat, ears and sinuses

The term URTI embraces a number of difThe term URTI embraces a number of different conditions:ferent conditions:

common cold (coryza)common cold (coryza)sore throat (pharyngitis, including tonsilsore throat (pharyngitis, including tonsil

litis)litis)acute otitis mediaacute otitis mediasinusitis sinusitis

Clinical PresentationClinical Presentation

The most common presentation is The most common presentation is a child with a combination of a a child with a combination of a painful throat, fever, nasal painful throat, fever, nasal blockage and discharge and blockage and discharge and earache.earache.

Cough is troublesome in many Cough is troublesome in many cases cases

URTIs may causeURTIs may cause

Difficulty in feeding in infants as Difficulty in feeding in infants as their noses are blocked and this their noses are blocked and this obstructs breathingobstructs breathing

Febrile convulsionsFebrile convulsionsPrecipitation of acute asthmaPrecipitation of acute asthma In infants, hospital admission may In infants, hospital admission may

be required exclude a more serious be required exclude a more serious infection infection

Brochiolitis Brochiolitis

Brochiolitis is the most common serioBrochiolitis is the most common serious respiratory infection of infancy. Twus respiratory infection of infancy. Two to three per cent of all infants are ado to three per cent of all infants are admitted to hospital with the disease eamitted to hospital with the disease each year during annual winter epidemich year during annual winter epidemics. Ninety per cent are aged 1-9 montcs. Ninety per cent are aged 1-9 months brochiolitis is rare after one year olhs brochiolitis is rare after one year old. Respiratory syncitial virus (RSV) is td. Respiratory syncitial virus (RSV) is the pathogen in 75-80% cases he pathogen in 75-80% cases

Clinical featuresClinical features

Coryzal symptoms precede a dry cough and increasing brCoryzal symptoms precede a dry cough and increasing breathlessness. Wheezing is often but not always present. Feathlessness. Wheezing is often but not always present. Feeding difficulties associated with increasing dyspnoea areeding difficulties associated with increasing dyspnoea are often the reason for admission to hospital. Recurrent ape often the reason for admission to hospital. Recurrent apnoea is a serious complication in infants in the first few mnoea is a serious complication in infants in the first few months of life. Infants born prematurely who develop brononths of life. Infants born prematurely who develop bronchopulmonary dysplasia and infants with congenital hearchopulmonary dysplasia and infants with congenital heart disease are more severely affected. The finding on examt disease are more severely affected. The finding on examination are characteristic:ination are characteristic:

Sharp, dry coughSharp, dry cough TachypnoeaTachypnoea Subcostal and intercostals recessionSubcostal and intercostals recession Hyperinflation of the chest Hyperinflation of the chest

Investigations Investigations

RSV can be identified rapidly using a RSV can be identified rapidly using a fluorescent antibody test on fluorescent antibody test on nasopharyngeal secretions. The nasopharyngeal secretions. The chest X-ray shows hyperinflation of chest X-ray shows hyperinflation of the lungs due to small airways the lungs due to small airways obstruction and air trapping. Blood obstruction and air trapping. Blood gas analysis, which is required in gas analysis, which is required in only the most severe cases, shows only the most severe cases, shows lowered arterial oxygen and raised lowered arterial oxygen and raised CO2 tension CO2 tension

ManagementManagement

Is supportive. Humidified oxygen is delivered into a head-Is supportive. Humidified oxygen is delivered into a head-box, the concentration required is ascertained using a pulbox, the concentration required is ascertained using a pulse oximeter. The child is monitored for apnoea. se oximeter. The child is monitored for apnoea.

Mist, antibiotics and steroids are not helpful. Mist, antibiotics and steroids are not helpful. Nebulised bronchodialators do not reduce the severity or Nebulised bronchodialators do not reduce the severity or

duration of the illness. duration of the illness. The antiviral drug ribavirin only marginally shortens viral The antiviral drug ribavirin only marginally shortens viral

excretion and clinical symptoms, and should be considerexcretion and clinical symptoms, and should be considered only for infants with underlying cardiopulmonary disoed only for infants with underlying cardiopulmonary disorders or immunodeficiency. rders or immunodeficiency.

Fluids may need to be given by nasogastric tube or intravFluids may need to be given by nasogastric tube or intravenously. enously.

Mechanical ventilation is required in about 2% of infants Mechanical ventilation is required in about 2% of infants admitted to hospitaladmitted to hospital

PrognosisPrognosis

Most infants recover from he acute Most infants recover from he acute infection within two weeks. infection within two weeks. However, as many as half will have However, as many as half will have recurrent episodes of cough and recurrent episodes of cough and wheeze over the next 3-5 years. wheeze over the next 3-5 years. Rarely, the illness is very severe Rarely, the illness is very severe and results in permanent damage and results in permanent damage o the airway o the airway

Pneumonia Pneumonia

A wide range of pathogens cause A wide range of pathogens cause pneumonia in childhood and pneumonia in childhood and different organisms affect different different organisms affect different age groups age groups

In newbornsIn newborns

The newborns is infected by organismThe newborns is infected by organisms from the mother’s genital tract. Ths from the mother’s genital tract. The most common is the Group B e most common is the Group B hae haemolytic streptococcus. Other pathogemolytic streptococcus. Other pathogens are ns are E.coliE.coli and other Gram-negative and other Gram-negative bacilli. bacilli. Chlamydia trachomatisChlamydia trachomatis is an u is an unusual but important pathogen. nusual but important pathogen.

In infancyIn infancy

In infancy, respiratory viruses, particuIn infancy, respiratory viruses, particularly RSV, are the most frequent cause larly RSV, are the most frequent cause but bacterial infection from but bacterial infection from StreptocoStreptococcus pneumoniae ccus pneumoniae and and Haemophilus iHaemophilus influenzae nfluenzae are also important. are also important. StaphylStaphylococcus aureus ococcus aureus is uncommon but cauis uncommon but causes severe infection ses severe infection

Older ChildrenOlder Children

As children become older, viruses becoAs children become older, viruses become less frequent pathogens and bacterime less frequent pathogens and bacterial infection more prominent. al infection more prominent. MycoplasmMycoplasma pneumoniaea pneumoniae is a common cause of pn is a common cause of pneumonia in school age children. Tubercueumonia in school age children. Tuberculosis should be considered at all ages losis should be considered at all ages

Clinical FeaturesClinical Features

Fever, cough breathlessness and lethargy foFever, cough breathlessness and lethargy following an upper respiratory tract infection llowing an upper respiratory tract infection are the usual presenting symptoms.are the usual presenting symptoms.

Breathing is rapid, shallow and gives the imBreathing is rapid, shallow and gives the impression that the child is afraid to breathe dpression that the child is afraid to breathe deeply. eeply.

Pleuritic chest pain, neck stiffness and abdoPleuritic chest pain, neck stiffness and abdominal pain may be present if there is pleural minal pain may be present if there is pleural inflammation. inflammation.

Clinical FeaturesClinical Features

Classical signs of consolidation with impaired peClassical signs of consolidation with impaired percussion, decreased breath sound and brochial brcussion, decreased breath sound and brochial breathing are often absent, particularly in infantsreathing are often absent, particularly in infants

The chest X-ray may slow lobar consolidation, paThe chest X-ray may slow lobar consolidation, patchy bronchopneumonia or, less commonly, cavitchy bronchopneumonia or, less commonly, cavitation of the lung. tation of the lung.

Pleural effusions are quite common, particularly Pleural effusions are quite common, particularly in bacterial pneumonia. in bacterial pneumonia.

Blood cultures, nasopharyngeal aspirates of viral Blood cultures, nasopharyngeal aspirates of viral isolation and a full blood count also be performeisolation and a full blood count also be performed in children needing hospitalisation.d in children needing hospitalisation.

ManagementManagement

It is not possible to differentiate reliably between bactIt is not possible to differentiate reliably between bacterial or viral infection on clinical or radiological grounerial or viral infection on clinical or radiological grounds, so all children diagnosed as have pneumonia shouds, so all children diagnosed as have pneumonia should receive antibiotics. ld receive antibiotics.

As it is unlikely for the pathogen to be known when treAs it is unlikely for the pathogen to be known when treatment is started, the choice of antibiotic is determineatment is started, the choice of antibiotic is determined by the child’s age, severity of illness and appearand by the child’s age, severity of illness and appearance of the chest X-ray. ce of the chest X-ray.

If intravenous therapy is required, activity against pneIf intravenous therapy is required, activity against pneumococci, umococci, H. influenzaeH. influenzae and and Staph. aures Staph. aures can be achican be achieved with a second-generation cephalosporin. eved with a second-generation cephalosporin.

ManagementManagement

Oral antibiotics are given for less severe infectiOral antibiotics are given for less severe infections. ons.

If If M.pneumoniae M.pneumoniae or or Chlamydia trachomatisChlamydia trachomatis pn pneumonia is suspected, erythromycin is given. eumonia is suspected, erythromycin is given.

Physiotherpy, anPhysiotherpy, an adequate fluid intake and oxadequate fluid intake and oxygen in severe pneumonia may be required. If ygen in severe pneumonia may be required. If a child has recurrent or persistent pneumonia, a child has recurrent or persistent pneumonia, investigations to exclude an underlying conditinvestigations to exclude an underlying condition such as cystic fibrosis or immunodeficiencion such as cystic fibrosis or immunodeficiency is indicatedy is indicated