An approach to a child with respiratory symptoms

Dr. Pushpa Raj Sharma Professor of Child Health Institute of Medicine

Common respiratory symptoms



Cough

 

Runny nose Tachypnoea

 

Snoring Stridor



Wheeze



Chest pain

  

Chest indrawing Haemoptysis Bluish discoloration

The most important sign: Tachypnea

 Cut off rate per minute  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

The most severe sign: Apnoea

 Acute life threatening event:  Apnoea > 20 second or associated with pallor, cyanosis, convulsion or limpness.

 Aetiology:  Prematurity  Sepsis  Meningitis/encephalitis  Drugs  Abnormal muscle tone

Cough

 Commonest respiratory symptom.

 Physiological to remove excess secretions or foreign body.

 Cough receptors in the posterior pharynx and large bronchi.

 Vagus/ glossopharyngeal: afferent to cough centre –pons /medulla . Efferent to - larynx/ diaphragm/ chest wall/abdominal wall/pelvic  Acute: lasts less than 2 weeks.

 Chronic: lasts more than 2 weeks.

Cough relating to time/ posture

 During or after feeding: aspiration  Night: asthma/ post nasal drip  Morning: bronchiectasis  With exercise: asthma  Absence during play: psychogenic  Seasonal: allergen  Cold: hyperreactivity

Differential diagnosis of chronic cough



Infants:

  

Infections

   Chlamydia Pertussis Bronchiolitis

Non infectious

    Asthma Domestic smoke pollution/passive smoke Gasro-eso. Reflux Foreign body

Congenital anamolies

 Tracheo-eso. fistula 

Children

  

Infectious

   Pneumonia Croup Post nasal drip/sinusitis

Non infectious

    Asthma Foreign body Tropical eosiniphilia Environmental irritants

Psychogenic

Treatment of chronic cough

  Over the counter cold preparation: 

no beneficial effect in children under 5 years

.

Post nasal drip:   Propped up position at 30 degree.

Treat accordingly for Allergic/non allergic rhinitis; Sinusitis  Macrolides: if

Mycoplasma / chlamydia

suspected.

  Nasal steroids/ decongestant Bronchodilators/ steroids  Specific treatment

Psychogenic Cough

 School aged children.     The child is often a high achiever; family stress Fixed timing but disappears during sleep and when distracted.

Diagnosis by observation and exclusion of other causes.

Treatment: Counseling, Normal saline gargle

Noisy Breathing

 Snoring   Grunting Stridor   Wheeze Ronchi

Snoring

 Inspiratory harsh sound irregularly  Associated with: large tonsils and adenoids; micrognathia, macroglossia, palatal palsy, pharyngeal hypotonia, obesity  Diagnostic test:  Sleep study, flexible bronchoscopy, lateral x-ray neck  Treatment needed if:  Sleeping difficulty; daytime somnolence, enuresis, growth failure, morning headache.

Stridor

   

Inspiratory harsh sound continuously

.

Can occur during expiration (intrathoracic) or both phase of respiration.

Asses the severity



Drooling of saliva, respiratory distress, unable to swallow, cyanosis Common causes:

 Infective: epiglottitis, laryngotracheobronchitis, tracheitis, retropharyngeal abscess (rare)      Malignancy: tumor compression, papilloma Allergic: angioneurotic oedema.

Congenital: laryngomalacia, laryngeal web, vascular ring, Aspiration: foreign body.

Neuronal: paralysis of vocal cord.

Investigation

 Blood count; Lateral neck X-ray; flexible bronchoscopy.

Grunting

 Low pitched expiratory sound.

 Protective phenomenon to prevent collapse of alveoli: PEEP  Causes:  Respiratory distress syndrome  Severe pneumonia, ARDS, severe sepsis  Investigations:  CXR; O2 saturation, blood gas

A child who wheezes: All wheezes are not Asthma

 Cough could be the only symptom.

 Triggering factor  Worse at night  History of repeated problem.

 Symptomatic improvement with bronchodilator.

 Gastro-esophageal reflux: Prokinetic.

Causes of Wheeze/Ronchi



Bilateral

      Asthma Bronchiolitis Mycoplasma Cystic fibrosis Alpha 1 antitrypsin deficiency Severe pneumonia 

Unilateral

      Pneumonia Foreign body Mediastinal mass Tuberculosis Bronchiectasis Vascualr ring

Chest Pain: Rarely cardiac origin in children.

 Infective  Pneumonia; pleural effusion, pneumothorax.

 Born Holm disease  Asthma  Trauma  Costochondritis  Psychogenic  Pericardial lesions

The severe signs: Chest Indrawing and Cyanosis



Chest in drawing:

     Increased airway resistance.

Contraction of diaphragm and pulling of ribs inside.

Negative pressure inside Breathing in and lower chest wall goes in.

Supra sternal, inter costal recession.



Cyanosis:

      Vasomotor instability in acrocyanosis.

Defective perfusion.

Defective ventilation.

Defective diffusion.

Methhaemoglobinemia Hyperoxia test

Haemoptysis: not common



Blood from posterior naso-pharynx or hematemesis: the difference.



Aetiology:

  Bronchiectasis.

Severe cough      Pneumonia Paragonimiasis Foreign body Severe measles Haemangioma/ AV malformation