Respiratory Disease In Childhood

1. Respiratory Disease In Childhood Nick Connolly Paediatric SpR NHS Tayside

2. Respiratory problems in children Neonatal respiratory problems Respiratory problems in older children Chronic Acute

3. Scenario An infant born at 30 weeks gestation develops respiratory distress at age 2 hours

6. Respiratory Distress Syndrome • Relative Surfactant deficiency • 1% all births • Predominantly in preterm – inverse relationship with gestation

7. Surfactant • Phospholipid • Apoproteins • Secreted at 30-32/40 • Lack of surfactant results in atelectasis and impairment of gas exchange • Production stimulated by steroids

8. Incidence of RDS relative to gestational age

9. Further problems • Ventilated • Sudden deterioration requiring increased oxygen • No breath sounds on the right side of chest

11. Pneumothorax • Air in pleural space • Increased incidence with IPPV, CPAP and ventilation • Other risk factors – RDS (stiff lungs) • Spontaneous - occurs in around 1% vaginal deliveries, 1.5% caesarean sections

13. Chronic Lung Disease • Oxygen requirement beyond 36 weeks corrected gestation plus evidence of pulmonary parenchymal disease on CXR • Generally follows RDS • Barotrauma, volume trauma, high inspired oxygen • Healing stage associated with continued lung growth over 2-3 years – often wheezy

14. Scenario New born full-term infant with severe breathing difficulty after birth ?Dextrocardia

16. Diaphragmatic Hernia Incidence:1/2400 Associated pulmonary hypoplasia Commonest- Posterolateral (Bochdalek), left-sided Avoid bag-mask IPPV? Respiratory support Surgical

18. Older Children

19. Weight(length/height)..plotted! ?clubbing Chest shape Auscultation Examination

20. Breathing tests

22. Chronic problems

23. Cystic fibrosis A 1 year-old child presenting with a prolonged history of cough, loose stools and failure to thrive A newborn infant with a raised immuno-reactive trypsin level on neonatal screening who is also found to be homozygous for the ΔF508 deletion

24. Cystic Fibrosis • Autosomal recessive • Carrier incidence roughly 1 in 25 people • Mutations in the CFTR gene • Multisystem disorder • Respiratory infections are prominent

26. Differential diagnosis Immune deficiency Ciliary dyskinesia Asthma Kartagener’s/ immotile cilia syndrome- rare

27. Scenario NM is a 7 month old infant with cystic fibrosis who was admitted with 2 chest infections. He grew Staphylococcus aureus on his respiratory secretions

29. Cystic Fibrosis Team Clinician Specialist nurse Clinical psychologist Social worker Physiotherapist Dietician

30. A 7-year child presents to your clinic with a 3-month history of cough worse at night or during active play Diagnosis: ASTHMA

31. Asthma – Diagnosis in ChildrenSIGN Guideline May 2008 Clinical Features that increase probability: • One or more : wheeze, cough, chest tightness, difficulty breathing • Atopy(personal or family history) • Widespread wheeze on auscultation • Response to Rx

32. Asthma – Diagnosis in ChildrenSIGN Guideline May 2008 High Probability – diagnosis of asthma likely (trial of Rx – further Ix if poor response) Low Probability – consider Ix & ? Referral Intermediate Probability: ?watchful waiting ?spirometry(response) ? Rx & evaluate

33. Asthma – Diagnosis in Children

34. Management Stage 1: Treat with inhaled beta-agonists when needed Stage 2: Treat with regular inhaled steroids Stage 3A: Regular inhaled steroids + Long acting beta agonists Stage 3B: Stage 3A + Leukotriene antagonists

36. Passive Smoking • Reduces birthweight by 250g • 4500 pregnancy losses p.a. • 30% increase in Perinatal Mortality • Teratogenic : airways, cleft lip/palate • Glue ear • Carcinogenic • 4 million children live with smoking parent • Increase likelihood of asthma attack

37. Acute problems

38. Acute asthma Cough and wheeze worsening over hours or days

40. Treatment Oxygen Nebulised bronchodilator Oral prednisolone IV salbutamol IV aminophylline IV magnesium Ventilatory support

42. Scenario • 6 week old presented with increased work of breathing and possible apnoes • URTI symptoms over last 2 days

43. Bronchiolitis • Viral infection – RSV • Usually under 18 months old • More severe in younger babies, ex prem, family of smokers • Tachypnoea, poor feeding, irritating cough • Apnoea in small babies • Treatment is supportive • Increased incidence of wheezing episodes in the next ?10 years

44. Scenario 10 year old girl with cough, high fever and sputum production Previously very well Clinical examination: Dullness on percussion Vocal fremitus and resonance Bronchial breathing

46. Pneumonia Neonates: GBS, E.coli, Klebsiella, Staph aureus Infants: Strep pneumoniae, Chlamydia School age: Strep pneumoniae, Staph aureus, Gr A strep, Bordetella, Mycoplasma, Legionella

47. Scenario A 2-year old child presenting with barking cough and difficulty in breathing of sudden onset

48. Differential Diagnosis Inhaled foreign body Laryngomalacia Epiglottitis and bacterial tracheitis Allergy Croup