noisy breathing

2. By : Dr hisham alrabty
Pediatric consultant and
pulmonologist

3. OBJECTIVES:
• Definition.
• Anatomy.
• Types.
• Causes.
• Clinical presentation.
• Diagnosis.
• Treatment.
We first will talk generally then specifically about some causes of noisy
breathing.

4. DEFINITION:
breathing cycle is not hearable normally.
So noisy breathing is hearable breathing
on other words breathing with any noise.
It happens due to obstruction to airways
either upper or lower due to any cause like
edema or foreign body or secretion.

5. ANATOMY OF R.S:
Consists of an upper respiratory tract (nose to larynx)
and a lower respiratory tract (trachea onwards) .
OR
Conducting portion transports air:
includes the nose, nasal cavity, pharynx, larynx, trachea,
and progressively smaller airways, from the primary
bronchi to the terminal bronchioles
Respiratory portion carries out gas exchange:
composed of small airways called respiratory
bronchioles and alveolar ducts as well as air sacs called
alveoli.

7. TYPES:
Three common types are:
1. Stridor: due to obstruction of
upper airways.
2. wheeze: due to obstruction to
lower airways.
3. Grunting: due to expiration
against partially closed epiglottis.

8. CAUSES:
 Causes of stridor:
1. Croup: parainfluenza virus.
2. Epiglottitis: hemophilus influenza bacteria.
3. Laryngomalacia: congenital.
4. Hypocalcaemia: rickets.
 Causes of wheeze:
1. Asthma: inflammatory.
2. Bronchiolitis: RSV.
 Causes of grunting:
Pneumonia: infections by bacteria and viruses.

9. HOW TO APPROACH A CASE OF NOISY
BREATHING?
i.e. how to diagnose the cause of noisy
breathing?
by the following steps:
1.History taking .
2.Full pediatric examination.
3.Aid of lab investigation or and imaging
studies.

10. STRIDOR:
abnormal, high-pitched sound produced by
turbulent airflow through a partially obstructed
airway at the level of the supraglottis, glottis,
subglottis, and/or trachea.
Types of it either inspiratory due to laryngeal
obstruction or expiratory due to
tracheobronchial obstruction or biphasic doe
to subglottic or glottic anomaly.

12. CAUSES OF STRIDOR:

13. CHARACTERISTIC EPIGLOTTITIS CROUP
Age Can occur in infants, older
children, or adults
Six months to six years
Onset Sudden Gradual
Location Supraglottic Subglottic
Temperature High fever Low-grade fever
Dysphagia Severe Mild or absent
Dyspnea Present Present
Drooling Present Absent
Cough Uncommon Characteristic cough
Position Sitting forward with mouth
open
Comfortable in different
positions
Radiography Positive thumb sign* Positive steeple sign

14. croup

15. Thumb sign of
epiglottitis

16. WHEEZE:
abnormal high-pitched or low-pitched
sound heard either by unaided human ear
or through stethoscope mainly during
expiration.
Commonly caused by asthma attack or
brochiolitis.

17. CLINICAL PRESENTATION:
i.e. How a patient of noisy breathing would be
presented clinically ???
History.
symptoms.
Signs.

18. HISTORY:
 Onset: acute or chronic.
 History of any associated symptom: fever.
 Duration:
 Family history:
 Social:
 Drug history:
 History of previous illness or addmission:recurrence like
asthma.
 Travel history:

19. SYMPTOMS:
 Fever: pneumonia.
 Cough: barking cough like croup.
 Wheeze: bronchiolitis.
 Stridor: croup.
 Hoarseness: croup.
 Feeding difficulty: pneumonia.
 Drooling: epiglottitis.
 Dyspnea.

20. SIGNS:
Signs or respiratory distress.
 Cyanosis.
 Tachypnea.
 Apnea.
 Flaring alae nasii.
 Recessions.
 Rhochi: asthma.
 Rales: pneumonia.
 Pleural rub.

21. Pathophysiological changes:

22. DIAGNOSIS:
Blood:
Cbc,abg,esr,crp,culture.
X.ray:
Cxr,lat.neck xr.
Specific:
Immunoflouroceness,pcr,viral serology.
Direct laryngnscopy,bronchoscopy.
Ct,mri.

23. • Progressive airway obstruction on inspiration.
• Note omega-shaped epiglottis.
Laryngomalacia

24. TREATMENT:
Supportive:
Humid oxygen,antipyretic,intravenous fluids.
Specific:
Antibiotics in
pneumonia,bronchodilators,steroids like
budesonide neb in croup,antiviral like
ribavirin neb in bronchiolitis.
Immunization:
Monoclonal antibody in bronchiolitis.

25. PROGNOSIS:
It depends on the cause ranging
from complete recovery to death.

26. BRONCHIOLITIS
(as example for wheeze):
Defined as acute inflammation of small
airways (bronchioles) by an infectious agent
which is most commonly being a virus.
Pathophysiologicaly it is a triad of sub
mucosal edema, mucus production,
narrowing of bronchioles.

27. CAUSES:
 RSV most common one.
 Human metapneumo virus.
 Adeno virus.
 Chlamydia and mycoplasma.

28. EPIDEMIOLOGY:
Sex: 1:1.
Age: 1st year of life, peak at 6 months old.
Season: autumn and winter.

29. CLINICAL PICTURE:
Patient usually presented with rep.distress
preceded by history of coryza and fever.
 Fever and rhinorrhea.
 Tachypnea.
 Wheeze.
 Breathlessness.
 Cyanosis.
 Difficult feeding.
 Cough.

30. DIAGNOSIS:
 CBC: leukocytosis.
 ESR and CRP.
 CXR.
 Nasopharyngeal scrapings for
immunofluorescence.
 PCR.

31. The radiographic changes of hyper inflated chest (flat
diaphragm, square chest shape).

32. TREATMENT:
 Humidified oxygen.
 I.V.fluids.
 Specific: ribavirin.
 Bronchodilators: controversial.
 Immunization: monoclonal antibody.

33. ADMISSION CRITERIA:
History of prematurity: apnea.
High rep.distress.
Difficulty in feeding.
Comorbidity.

34. PROGNOSIS:
Almost all patient will recover of it and some will be
asthmatic later on.
My paper was about the asthma bronchiolitis
relationship which was done in 2003 and showed
53.5% of Libyan asthmatic children had history of
bronchiolitis.

35. GRUNTING:
When a patient exhales against a partially
closed glottis this type of noisy breathing
produced.
i.e. patient breathing in pain .
Commonly happens with pneumonia or
bronchiolitis.

36. PNEUMONIA
(as example for grunting):
It is defined as infection of lung parenchyma by
infectious agent causing acute inflammation of one
lobe or lung or both lungs.
The United Nations Children's Fund (UNICEF)
estimates that pediatric pneumonia kills 3 million
children worldwide each year.
Pneumonia can occur at any age, although it is more
common in younger children.
Pneumonia accounts for 13% of all infectious
illnesses in infants younger than 2 years.

37. ETIOLOGY:
Again the viruses remain the common cause of pediatric
pneumonia at all ages but bacterial causes are age
dependent so:
 Less than 2 months:
Listeria monocytogenes,streptococci grp B and gram
negative bacteria.
 Infants and preschool children:
Strep pneumoniae, Staph aureus, and nontypeable H
influenzae.
 School age children:
Mycoplasma accounts for 14-35% of pneumonia
hospitalizations in this age group.

38. EPIDEMIOLOGY:
Pneumonia and other lower respiratory tract
infections are the leading cause of death
worldwide.
Approximately 150 million new cases of
pneumonia occur annually among children
younger than 5 years worldwide, accounting for
approximately 10-20 million hospitalizations.

39. CLINICAL PICTURE:
 History of fever and wet cough which might
be preceded by upper respiratory tract
infection.
 Then the patient will develop progressive
dyspnea.
 There could be a history of poor oral intake.
 History of chest pain.
 History of noisy breathing i.e. grunting.

40. ON EXAMINATION:
 Fever.
 Increased respiratory rate.
 Central cyanosis and flaring alae nasii.
 Toxic look i.e. patient looks lethargic and
exhausted.
 Chest recessions.
 Decreased air entry either unilateral or bilateral.
 Bronchial breathing.
 Pleural rub.
 Rales.

41. DIAGNOSTIC WORK UP:
 Lab tests:
abg,cbc,esr,crp and blood culture.
 CXR:
opacity homogenous or heterogeneous.
 Ct chest with contrast.
 Brochoscopy:
for biopsy or lavage.

42. Rt side lobar pneumonia

43. TREATMENT:
 Supportive in form of oxygen and intravenous fluids.
 Specific in form of antibacterial:
1.for children less than 2 months age:
ampicillin and 3rd generation cephalosporine.
2.preschool children:
beta lactam antibacterial +- macrolide.
3.school children:
macrolide antibacterial.

44. COMPLICATIONS:
 Acute :
 Local:
like lung abcess,pleural effusion and
pneumothorax.
 General:
spesis,respiratory failure and dehydration.
 Chronic:
Bronchiectasis.

45. PROGNOSIS:
It is generally good certainly if the
diagnosis made in time and the
patient given proper treatment.