Respiratory disorders in children

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Respiratory disorders in children

  1. 1. Respiratory Disorders in Children Celia Sy, M.D. FPPS,FPAPP Pediatric Pulmonologist
  2. 2. Anatomy URT LRT
  3. 3. Dilated esophagus
  4. 4. Stages of Lung Development <ul><li>1. Embryonic </li></ul><ul><ul><ul><li>Approx 4 th wks of gestation </li></ul></ul></ul><ul><ul><ul><li>Develop of the 2 main stem bronchus </li></ul></ul></ul><ul><ul><ul><li>Seperation of forgut fr coelomic cavity </li></ul></ul></ul><ul><li>2. Pseudoglandular </li></ul><ul><ul><ul><li>6 th weeks of gestation </li></ul></ul></ul><ul><ul><ul><li>Separation of trachea from forgut </li></ul></ul></ul><ul><ul><ul><li>Formation of diaphragm </li></ul></ul></ul>
  5. 5. Chest X-Ray The Intensive Course in Pediatric Pulmonology Congenital Diaphragmatic Hernia
  6. 6. <ul><li>3. Cannalicular </li></ul><ul><ul><ul><li>16 th and 26-28 th weeks of gestation </li></ul></ul></ul><ul><ul><ul><li>Presence of type I & II pneumatocytes </li></ul></ul></ul><ul><ul><ul><li>Limited gas exchanges by 22 wks </li></ul></ul></ul><ul><li>4. Saccular </li></ul><ul><ul><ul><li>26 th -28 th wks of gestation </li></ul></ul></ul><ul><ul><ul><li>Widen of terminal airways & saccule formation </li></ul></ul></ul><ul><li>5. Alveolar </li></ul><ul><ul><ul><li>29 th wks – birth </li></ul></ul></ul>
  7. 7. Question 1 <ul><li>Tracheoesophageal fistula is formed at what stages of lung development? </li></ul><ul><ul><li>Pseudoglandular stage </li></ul></ul><ul><li>Diaphragmatic hernia is formed at what stages of lung development? </li></ul><ul><ul><li>Pseudoglandular stage </li></ul></ul><ul><li>Gas exchange is first presence at what stage of lung development? </li></ul><ul><ul><li>Canalicular stage </li></ul></ul>
  8. 8. Static Lung Volume <ul><li>Tidal volume </li></ul><ul><ul><ul><li>Volume of normal breathing </li></ul></ul></ul><ul><li>Vital Capacity </li></ul><ul><ul><ul><li>Maximal expired volume after maximal inhalation </li></ul></ul></ul><ul><ul><ul><li>Inspiratory reserve volume (IRV) + tidal volume (TV) + Expiratory reserve volume (ERV) </li></ul></ul></ul>
  9. 9. <ul><li>Residual volume </li></ul><ul><ul><ul><li>Volume remaining after maximal exhalation </li></ul></ul></ul><ul><li>Functional residual capacity </li></ul><ul><ul><ul><li>Expiratory reserve volume (ERV) + residual volume (RV) </li></ul></ul></ul><ul><li>Total lung capacity </li></ul><ul><ul><ul><li>vital capacity (VC) + residual volume (RV) </li></ul></ul></ul>
  10. 10. Upper Respiratory Tract Infections <ul><li>Acute Nasopharyngitis </li></ul><ul><ul><ul><li>“ URI”, common colds </li></ul></ul></ul><ul><ul><ul><li>Average of 3- 8 URI/year </li></ul></ul></ul><ul><ul><ul><li>Rhinovirus </li></ul></ul></ul><ul><ul><ul><li>First 2 yrs. of life </li></ul></ul></ul><ul><ul><ul><li>Fever, irritability, sneezing </li></ul></ul></ul><ul><ul><ul><li>Differential dx: foreign body obstruction, allergic rhinitis </li></ul></ul></ul><ul><ul><ul><li>Otitis media-most common complication </li></ul></ul></ul>
  11. 11. <ul><li>Acute Pharyngitis </li></ul><ul><ul><ul><li>“ tonsillitis, tonsillopharyngitis” </li></ul></ul></ul><ul><ul><ul><li>Group A b- hemolytic streptococcus </li></ul></ul></ul><ul><ul><ul><li>4 – 7 yrs. Old </li></ul></ul></ul><ul><ul><ul><li>Headache, abdominal pain, vomiting, petechial mottling of soft palate (strep) </li></ul></ul></ul><ul><ul><ul><li>Throat swab for strep antigen, throat culture </li></ul></ul></ul><ul><ul><ul><li>Otitis media- most common complication </li></ul></ul></ul><ul><ul><ul><li>Penicillin – drug of choice for strep </li></ul></ul></ul>
  12. 12. <ul><li>Retropharyngeal Abscess </li></ul><ul><ul><ul><li>Complication of Bacterial pharyngitis </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Retropharyngeal space - potential space bet posterior pharyngeal wall & prevertebral fascia </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Most frequent in children < 3 yr of age </li></ul></ul></ul><ul><ul><ul><li>Grp A hemolytic strep, oral anaerobes, staph aureus </li></ul></ul></ul><ul><ul><ul><li>Fever, difficulty of swallowing, drooling </li></ul></ul></ul><ul><ul><ul><li>Bulging of posterior pharyngeal wall </li></ul></ul></ul><ul><ul><ul><li>Complication: aspiration of pus </li></ul></ul></ul><ul><ul><ul><li>Meds: semisynthetic penicillin. Clindamycin, ampicillin-sulbactam </li></ul></ul></ul>
  13. 13. <ul><li>Sinusitis </li></ul><ul><ul><li>Maxillary & ethmoid – anatomically present in utero </li></ul></ul><ul><ul><li>Frontal – develop by age of 1-2 yr </li></ul></ul><ul><ul><li>Frontal & Sphenoid –radiologically present only at 5-6 yrs of age </li></ul></ul><ul><ul><li>Strep pneumonea, moraxella catarrhalis, H. influenzae </li></ul></ul><ul><ul><li>Cough, nasal discharge – most common symptoms </li></ul></ul><ul><ul><li>Fever, peri orbital edema, facial pain </li></ul></ul><ul><ul><li>(+) air fluid level & opacification </li></ul></ul><ul><ul><li>Complications: meningitis, subdural abscess </li></ul></ul>
  14. 14. <ul><li>Epiglottis </li></ul><ul><ul><ul><li>“ supraglottitis” </li></ul></ul></ul><ul><ul><ul><li>H. influenza b </li></ul></ul></ul><ul><ul><ul><li>2 – 7 yrs old </li></ul></ul></ul><ul><ul><ul><li>Severe airway obstruction death </li></ul></ul></ul><ul><ul><ul><li>Inspiratory stridor </li></ul></ul></ul><ul><ul><ul><li>“ tripod sign” </li></ul></ul></ul><ul><ul><ul><li>Cherry red epiglottis </li></ul></ul></ul><ul><ul><ul><li>Keep airway patent </li></ul></ul></ul><ul><ul><ul><li>Meds: cephalosporin </li></ul></ul></ul>
  15. 15. <ul><li>Croup </li></ul><ul><ul><ul><li>“ Laryngotracheobronchitis” or LTB </li></ul></ul></ul><ul><ul><ul><li>Fever, brassy cough, inspiratory stridor </li></ul></ul></ul><ul><ul><ul><li>Occurs in young children </li></ul></ul></ul><ul><ul><ul><li>Mx: steam inhalation, dexamethasone, racemic epinephrine </li></ul></ul></ul><ul><ul><ul><li>Contraindicated: opiates or sedatives </li></ul></ul></ul>
  16. 16. Chest X-Ray The Intensive Course in Pediatric Pulmonology Acute Laryngotracheobronchitis
  17. 17. <ul><li>Laryngitis </li></ul><ul><ul><ul><li>Acute Spasmodic Laryngitis </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Similar to LTB w/ absent of history of URI </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Afebrile, barking cough </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Acute Infective Laryngitis </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Caused by viruses </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Subglottic area – principal site of obstruction </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Loss of voice </li></ul></ul></ul></ul></ul>
  18. 18. <ul><li>Bacterial Tracheitis </li></ul><ul><ul><ul><li>Life threathening airway obstruction </li></ul></ul></ul><ul><ul><ul><li>S. aureus </li></ul></ul></ul><ul><ul><ul><li>< 3 yrs old </li></ul></ul></ul><ul><ul><ul><li>Follows an apparent viral infection, measles </li></ul></ul></ul><ul><ul><ul><li>As complication of intubation </li></ul></ul></ul><ul><ul><ul><li>Direcr laryngoscopy – pus </li></ul></ul></ul><ul><ul><ul><li>Mx: intubation/ tracheostomy, antibiotics </li></ul></ul></ul>
  19. 19. Lower Respiratory Tract Infections <ul><li>Acute bronchitis </li></ul><ul><ul><ul><li>Gradual onset </li></ul></ul></ul><ul><ul><ul><li>Preceeded by URTI </li></ul></ul></ul><ul><ul><ul><li>Fever, conjunctiva injection, rhinitis, dry hacking, non-productive cough </li></ul></ul></ul><ul><ul><ul><li>Chest pain, wheezing, rhonchi </li></ul></ul></ul>
  20. 20. <ul><li>Bronchiolitis </li></ul><ul><ul><ul><li>Respiratory syncytial virus – 50% </li></ul></ul></ul><ul><ul><ul><li>Occurs during the 1 st 2 yrs of life (peak – 6 month of age) </li></ul></ul></ul><ul><ul><ul><li>“ ball valve” type of obstruction hypoxemia V/Q mismatch respiratory failure </li></ul></ul></ul><ul><ul><ul><li>Critical phase – first 48 – 72 hrs </li></ul></ul></ul><ul><ul><ul><li>Fever. Cough, wheezing, dyspnea </li></ul></ul></ul><ul><ul><ul><li>CXR – increase AP diameter w/ hyperinflation </li></ul></ul></ul><ul><ul><ul><li>MX: oxygen, ribavirin (virazole) </li></ul></ul></ul>
  21. 21. <ul><li>Bronchiolitis Obliterans </li></ul><ul><ul><ul><li>Progressive airways obstruction </li></ul></ul></ul><ul><ul><ul><li>Inflammation & granulations tissue formation of small airways </li></ul></ul></ul><ul><ul><ul><li>Associated with adenovirus infection </li></ul></ul></ul><ul><ul><ul><li>Common complications of lung transplant </li></ul></ul></ul><ul><ul><ul><li>May be delayed by corticosteroids </li></ul></ul></ul>
  22. 22. <ul><li>Pneumonia </li></ul><ul><ul><ul><li>Causative agents: bacteria, virus, mycoplasma, aspiration </li></ul></ul></ul><ul><ul><ul><li>Severity: mild, moderate, severe </li></ul></ul></ul><ul><ul><ul><li>WHO: No pneumonia, pneumonia, severe pneumonia </li></ul></ul></ul><ul><ul><ul><li>Location: lobular, lobar, bronchopneumonia </li></ul></ul></ul>
  23. 23. Chest X-Ray The Intensive Course in Pediatric Pulmonology Normal
  24. 24. Chest X-Ray The Intensive Course in Pediatric Pulmonology Pneumonia
  25. 25. <ul><li>Bacterial Pneumonia </li></ul><ul><ul><li>Chidren > 2 months of age </li></ul></ul><ul><ul><ul><li>Most common microorganisms: S. pneumoniae </li></ul></ul></ul><ul><ul><ul><ul><li> H. influenzae </li></ul></ul></ul></ul><ul><ul><ul><li>Most common symptoms: fever, cough, dyspnea </li></ul></ul></ul><ul><ul><li>Children < 2 months old </li></ul></ul><ul><ul><ul><li>Most common microorganisms: Group b strep </li></ul></ul></ul><ul><ul><ul><li> E. coli </li></ul></ul></ul><ul><ul><ul><li>+/- fever </li></ul></ul></ul><ul><ul><ul><li>Tachypnea - most reliable sign </li></ul></ul></ul><ul><ul><li> </li></ul></ul>
  26. 26. <ul><li>Pneumococcal pneumonia </li></ul><ul><ul><li>90% cases </li></ul></ul><ul><ul><li>Lobar involvement </li></ul></ul><ul><ul><li>CXR: lobar consolidation </li></ul></ul><ul><li>H. Influenzae pneumonia </li></ul><ul><ul><li>Insidious onset </li></ul></ul><ul><ul><li>Predeed by URTI </li></ul></ul><ul><ul><li>Nosocomial infection </li></ul></ul><ul><ul><li>no characteristics clinical / radiological patterns </li></ul></ul>
  27. 27. Chest X-Ray The Intensive Course in Pediatric Pulmonology Consolidation
  28. 28. <ul><li>Staphylococcal pneumonia </li></ul><ul><ul><li>Occurs in young infants </li></ul></ul><ul><ul><li>Associated with septicemia, skin infections, measles </li></ul></ul><ul><ul><li>Serious, rapid progressive course of illness </li></ul></ul><ul><ul><li>Extensive bilateral lung involvement </li></ul></ul><ul><ul><li>CXR: nodular infiltrates, multiple abscesses, empyema, pneumothorax </li></ul></ul><ul><ul><li>Meds: penicillinase-resistant penicillin </li></ul></ul>
  29. 29. Chest X-Ray The Intensive Course in Pediatric Pulmonology Staphylococcal Pneumonia
  30. 30. <ul><li>Klebsiella pneumonia </li></ul><ul><ul><li>Thick-rusty sputum </li></ul></ul><ul><ul><li>Bulging of fissures </li></ul></ul><ul><ul><li>Pulmonary abscess & cavitations </li></ul></ul>
  31. 31. <ul><li>Pseudomonas pneumonia </li></ul><ul><ul><li>Immunocompromised, debilitating patients </li></ul></ul><ul><ul><ul><li>Prolonged mechanical ventilatory support </li></ul></ul></ul><ul><ul><ul><li>HIV </li></ul></ul></ul><ul><ul><li>CXR: presence of necrosis </li></ul></ul>
  32. 32. Case 1 <ul><li>3 y/o F, fever, cough & difficulty of breathing of 3 days duration. PPE: febrile, alar flaring, stridor, drooling of the saliva. Patient was noted to assume a “tripod” position </li></ul><ul><li>Questions: </li></ul><ul><ul><li>Where is the site of the lesion? </li></ul></ul><ul><ul><ul><li>A. URT B. LRT </li></ul></ul></ul><ul><ul><li>What is the probable diagnosis in this case? </li></ul></ul><ul><ul><ul><li>A. pneumonia B. laryngitis C. epiglottitis </li></ul></ul></ul><ul><ul><li>What are the expected clinical findings? </li></ul></ul><ul><ul><ul><li>A. bulging of posterior pharyngeal wall </li></ul></ul></ul><ul><ul><ul><li>B. cherry red epiglottis </li></ul></ul></ul><ul><ul><ul><li>C. floppy epiglottis </li></ul></ul></ul><ul><ul><li>What is the antibiotic of choice? </li></ul></ul><ul><ul><ul><li>A. penicillin B. cephalosporin c. ampicillin </li></ul></ul></ul><ul><ul><li>Preventive measures is best achieved by: </li></ul></ul><ul><ul><ul><li>A. vaccination B. primary chemoprophylaxis C. post-exposure antibiotics </li></ul></ul></ul>
  33. 34. Non-Infectious Disorders of the Respiratory Tract <ul><li>Acquired </li></ul><ul><ul><li>Allergic rhinitis </li></ul></ul><ul><ul><li>Epistaxis </li></ul></ul><ul><ul><li>FB obstruction/ </li></ul></ul><ul><ul><li>aspiration </li></ul></ul><ul><ul><li>Nasal polyps </li></ul></ul><ul><ul><li>Nasal septal deviation / </li></ul></ul><ul><ul><li>perforation </li></ul></ul><ul><li>Congenital </li></ul><ul><ul><li>Nasal hypoplasia </li></ul></ul><ul><ul><li>High arch palate </li></ul></ul><ul><ul><li>Choanal atresia </li></ul></ul><ul><ul><li>Laryngomalacia </li></ul></ul><ul><ul><li>Tracheomalacia </li></ul></ul><ul><ul><li>Congenital Central Hypoventilation Syndrome </li></ul></ul>
  34. 35. Congenital <ul><li>Choanal atresia </li></ul><ul><ul><li>Unilateral or bilateral bony(90%)or membranous(10%) septum between the nose & the pharynx </li></ul></ul><ul><ul><li>Associated w/ CHARGE syndrome – c oloboma , h eart disease , a tresia choanae , r etarded growth & development or CNS anomalies or both; g enital anomalies or hypoganadism or both; & e ar anomalies or deafness, or both </li></ul></ul><ul><ul><li>Dx: inability to pass a firm catheter through each nostril 3 -4 cm into the nasopharnx </li></ul></ul>
  35. 36. Congenital <ul><li>Laryngomalacia </li></ul><ul><ul><li>Most common congenital laryngeal abnormality </li></ul></ul><ul><ul><li>Flabbiness of epiglottis & supraglottic apperture </li></ul></ul><ul><ul><li>Floppy arytenoid cartilages </li></ul></ul><ul><ul><li>Short aryepiglottic folds </li></ul></ul><ul><ul><li>Noisy, crowing respiratory sounds during inspiration – “Halak” </li></ul></ul><ul><ul><li>Diagnosed by direct laryngoscopy </li></ul></ul><ul><ul><li>Resolves spontaneously </li></ul></ul>
  36. 40. Congenital Central Hypoventilation Syndrome CCHS (Ondine’s curse) <ul><li>Primary CNS defect </li></ul><ul><li>Term, AGA </li></ul><ul><li>Resp failure, slow & irregular respiratory pauses, cyanosis </li></ul><ul><li>appear on the 1 st day of life </li></ul><ul><li>Px fail to respire adequately during sleep, not during wakefullness </li></ul><ul><li>No sensitivity to carbon dioxide & hypoxemia </li></ul><ul><li>No ventilatory response to CO2 during sleep </li></ul><ul><li>PCO2 to 80 -90 mmHg during sleep </li></ul>
  37. 41. Obstructive Sleep Apnea (OSA) <ul><li>Upper airway obstruction 2 nd to adenotonsillar hypertrophy </li></ul><ul><li>Triad: Snoring, noctural breathing difficulty, respiratory pauses </li></ul><ul><li>Polycythemia, respiratory acidosis & metabolic alkalosis, RVH </li></ul><ul><li>PSG (polysonograph)- diagnostic “ gold standard” </li></ul>
  38. 42. Acquired <ul><li>Epistaxis </li></ul><ul><ul><li>Kiesselbach’s plexus – most common location for bleeding </li></ul></ul><ul><ul><li>Stop spontaneously in most cases </li></ul></ul><ul><ul><li>Local application of oxymetazoline or neosynephrine (0.25 – 1 %) </li></ul></ul>
  39. 43. Acquired <ul><li>Nasal polyps </li></ul><ul><ul><li>Benign pedunculated tumors formed from edematous, chronically inflamed nasal mucosa </li></ul></ul><ul><ul><li>Glistening, gray, grape like masses squeezed bet the nasal turbinates & septum </li></ul></ul><ul><ul><li>Cystic fibrosis – most common childhood cause of nasal polyposis </li></ul></ul><ul><ul><li>Mx: intranasal steroids, surgical removal </li></ul></ul>
  40. 44. Acquired <ul><li>Foreign Bodies </li></ul><ul><ul><li>Location: nose, trachea, bronchus </li></ul></ul><ul><ul><li>Sudden onset </li></ul></ul><ul><ul><li>Croupy, barking cough </li></ul></ul><ul><ul><li>Hoarseness, aphonia (larynx) </li></ul></ul><ul><ul><li>Recurrent lobar pneumonia, intractable asthma </li></ul></ul>
  41. 45. Chest X-Ray The Intensive Course in Pediatric Pulmonology Foreign Body Aspiration
  42. 46. 2y/o child presenting with chronic cough, bronchiectasis on xray, with digital clubbing
  43. 47. Ballpen tip found in the left lower bronchus of a child with persistent respiratory symptoms & abnormal xray (persistent atelectasis, left lung) Patient subsequently underwent removal of the foreign body via rigid bronchoscopy by the ENT. National Children’s Hospital 2004
  44. 48. Plant fragments Royal Children’s Hospital 2008
  45. 49. Aspiration Pneumonia <ul><ul><li>Predisposing condition </li></ul></ul><ul><ul><ul><li>Congenital </li></ul></ul></ul><ul><ul><ul><ul><li>Esophageal atresia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cleft lip/palate </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Duodenal obstruction </li></ul></ul></ul></ul><ul><ul><ul><ul><li>GER </li></ul></ul></ul></ul><ul><ul><ul><li>Acquired </li></ul></ul></ul><ul><ul><ul><ul><li>Debilitated infants </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cerebral palsy </li></ul></ul></ul></ul>
  46. 50. <ul><li>Materials commonly aspirated: </li></ul><ul><ul><li>Milk, cereals, food </li></ul></ul><ul><ul><li>Vomitus </li></ul></ul><ul><ul><li>Baby powder </li></ul></ul><ul><ul><li>Hydrocarbon (Kerosene) </li></ul></ul><ul><ul><li>Lipoid materials </li></ul></ul><ul><ul><ul><li>Medicated oils </li></ul></ul></ul><ul><ul><ul><li>Cod liver oils </li></ul></ul></ul>
  47. 51. Kerosene Aspiration <ul><li>Most common in the Philippines </li></ul><ul><li>Low viscosity, High volatility </li></ul><ul><li>cough, fever, dyspnea, hypoxemia, </li></ul><ul><li>cyanosis </li></ul><ul><li>Pneumothorax, subcutaneous empysema, pleural effusion </li></ul><ul><li>All symptomatic should be admitted for observation </li></ul><ul><li>Gastric lavage is contraindicated </li></ul>
  48. 52. Chest X-Ray The Intensive Course in Pediatric Pulmonology Pneumothorax
  49. 53. Chest X-Ray The Intensive Course in Pediatric Pulmonology Pleural Effusion
  50. 54. Kerosene Aspiration <ul><li>No patient should be sent home in < 6 hrs. </li></ul><ul><li>All symptomatic patient should be admitted </li></ul><ul><li>Gastric lavage is containdicated </li></ul>
  51. 55. Congenital Lung Anomalies <ul><li>Lung agenesis </li></ul><ul><ul><li>Bilateral – incompatible with life </li></ul></ul><ul><li>Lung hypoplasia </li></ul><ul><ul><li>Associated w/ persistent fetal hypertension & ipsilateral diaphragmatic hernia </li></ul></ul>
  52. 56. <ul><li>Pulmonary Sequestration </li></ul><ul><ul><li>Mass of non-functioning embryonic & cystic pulmonary tissue that receives its blood supply from the systemic artery </li></ul></ul><ul><ul><li>2 Types: </li></ul></ul><ul><ul><ul><li>Intralobar </li></ul></ul></ul><ul><ul><ul><li>Extralobar </li></ul></ul></ul><ul><ul><li>Angiogram – “gold standard” diagnostic tool </li></ul></ul>
  53. 57. Chest X-Rays The Intensive Course in Pediatric Pulmonology
  54. 58. Aortogram The Intensive Course in Pediatric Pulmonology Pulmonary Sequestration
  55. 59. <ul><li>Bronchogenic Cysts </li></ul><ul><ul><li>Abnormal budding of the tracheal diverticulum of the forgut </li></ul></ul><ul><ul><li>Lined w/ ciliated epithelium </li></ul></ul><ul><ul><li>Located at the midline between the trachea & esophagus or carina </li></ul></ul><ul><ul><li>Cyst with air-fluid level </li></ul></ul>
  56. 60. Chest X-Ray The Intensive Course in Pediatric Pulmonology Bronchogenic Cyst
  57. 61. <ul><li>Congenital Cystic Adenomatoid Malformation (CCAM) </li></ul><ul><ul><li>Malformation of the terminal bronchiolar structure </li></ul></ul><ul><ul><li>Contains small amount of normal lung tissue w/ many glandular elements </li></ul></ul><ul><ul><li>Single lobe of one lung is enlarged & often cystic </li></ul></ul><ul><ul><li>Ipsilateral lung may be hypoplastic </li></ul></ul><ul><ul><li>Left lower lobe – most common </li></ul></ul>
  58. 62. <ul><li>Congenital Lobar Emphysema </li></ul><ul><ul><li>Single or multiple lobe </li></ul></ul><ul><ul><li>Left upper lobe – most common </li></ul></ul>
  59. 63. Tuberculosis in Children <ul><li>Etiology: mycobacterium tuberculosis </li></ul><ul><li>Droplet’s inhalation lungs </li></ul><ul><li>Incubation peroid: 2 - 10 weeks </li></ul>
  60. 64. Tuberculin Test <ul><li>Mantoux test </li></ul><ul><li>PPD- RT23 (2-TU PPD-RT23) </li></ul><ul><ul><li>WHO & IUATLD </li></ul></ul><ul><li>5-TU PPD-S </li></ul><ul><ul><li>ATS & CDC </li></ul></ul><ul><li>0.1 ml of the 2TU of RT23 will have a tuberculin reactivity similar to 0.1 ml of the 5 TU of PPS-S </li></ul>
  61. 65. <ul><li>Positive PPD </li></ul><ul><li>> 10 mm induration </li></ul><ul><ul><ul><li>Children < 5 yr old </li></ul></ul></ul><ul><ul><ul><li>BCG immunized children </li></ul></ul></ul><ul><li>> 5 mm induration </li></ul><ul><ul><ul><li>Children > 5 yr old </li></ul></ul></ul><ul><ul><ul><li>Non-BCG vaccinated children </li></ul></ul></ul>
  62. 66. <ul><li>Accelerated BCG reaction on “BCG test” </li></ul><ul><ul><li>Induration (at least 5 mm) – 48 – 72 hrs </li></ul></ul><ul><ul><li>Pustules - 5 – 7 days </li></ul></ul><ul><ul><li>Healing – 2 – 3 weeks </li></ul></ul>
  63. 67. TB Infection vs. Disease <ul><li>TB infection </li></ul><ul><ul><li>(+) tuberculin skin test </li></ul></ul><ul><ul><li>No sign & symptoms </li></ul></ul><ul><ul><li>(-) CXR </li></ul></ul><ul><li>TB disease </li></ul><ul><ul><li>(+) tuberculin skin test </li></ul></ul><ul><ul><li>(+) signs & symptoms </li></ul></ul><ul><ul><li>(+) CXR </li></ul></ul>
  64. 68. TB Classification <ul><li>Class I (TB Exposure) </li></ul><ul><ul><li>(+) exposure to anadult/adolescent w/ activeTB </li></ul></ul><ul><ul><li>(-) signs & symptoms of TB </li></ul></ul><ul><ul><li>(-) mantoux tuberculin test </li></ul></ul><ul><ul><li>(-) chest x-ray </li></ul></ul>
  65. 69. <ul><li>Class II (TB infection) </li></ul><ul><ul><li>(+/-) history of exposure </li></ul></ul><ul><ul><li>(+) mantoux tuberculin test </li></ul></ul><ul><ul><li>(-) signs & symptoms of TB </li></ul></ul><ul><ul><li>(-) chest radiograph </li></ul></ul>
  66. 70. <ul><li>Class III (TB disease) </li></ul><ul><ul><li>A child who has active TB has 3 or more of the following criteria: </li></ul></ul><ul><ul><ul><li>(+) hx of exposure to an adult/adolescent w active TB disease </li></ul></ul></ul><ul><ul><ul><li>(+) mantoux tuberculin test </li></ul></ul></ul><ul><ul><ul><li>(+) signs & symptoms: one or more of the ff should be present: </li></ul></ul></ul><ul><ul><ul><ul><li>Cough/wheezing > weeks; fever > 2 weeks </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Painless cervical &/or other lymphadenopathy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Poor weight gain; failure to make a quick return to normal after an infection (measles, tonsillitis, whooping cough); failure to respod to appropriate antibiotic therapy(pneumonia, otitis media) </li></ul></ul></ul></ul><ul><ul><ul><li>Abnormal chest x-ray suggestive of TB </li></ul></ul></ul><ul><ul><ul><li>Laboratory findings suggestive of TB </li></ul></ul></ul>
  67. 71. <ul><li>Class IV (TB inactive) </li></ul><ul><ul><li>A child/adolescent with or without history of previous TB and any of the following: </li></ul></ul><ul><ul><ul><li>(+/-) previous chemotherapy </li></ul></ul></ul><ul><ul><ul><li>(+) radio logic evidence of healed/calcified TB </li></ul></ul></ul><ul><ul><ul><li>(+) mantoux tuberculin test </li></ul></ul></ul><ul><ul><ul><li>(-) signs & symptoms </li></ul></ul></ul><ul><ul><ul><li>(-) smear/culture for M.tuberculosis </li></ul></ul></ul>
  68. 72. Chest X-Ray The Intensive Course in Pediatric Pulmonology Miliary TB
  69. 74. Good luck & thank you for listening!
  70. 75. Management of Newborns of Tuberculous Mothers <ul><li>Case 1 </li></ul><ul><ul><li>Mother – TB infection </li></ul></ul><ul><ul><ul><ul><ul><li>(+) PPD , No evidence of disease </li></ul></ul></ul></ul></ul><ul><ul><li>Baby – </li></ul></ul><ul><ul><li>give BCG at birth </li></ul></ul>
  71. 76. <ul><li>Case 2 </li></ul><ul><ul><li>Mother – TB disease </li></ul></ul><ul><ul><ul><ul><ul><li>Treatment for 2 weeks or more </li></ul></ul></ul></ul></ul><ul><ul><li>Baby – </li></ul></ul><ul><ul><li>Start isoniazid at birth </li></ul></ul><ul><ul><ul><ul><li>- do mantoux test at 4 – 6 weeks </li></ul></ul></ul></ul><ul><ul><ul><ul><li> PPD (-) continue INH </li></ul></ul></ul></ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul><ul><ul><ul><ul><li> Repeat PPD after 3 months </li></ul></ul></ul></ul><ul><ul><ul><ul><li> PPD (-) D/C INH, give BCG </li></ul></ul></ul></ul><ul><ul><ul><ul><li> PPD (+) CXR (-) INH 6 more months </li></ul></ul></ul></ul><ul><ul><ul><ul><li> CXR (+) INH, RIF 6 month PZA 2 month </li></ul></ul></ul></ul>
  72. 77. <ul><li>Case 3 </li></ul><ul><ul><li>Mother – TB disease, untreated </li></ul></ul><ul><ul><ul><ul><ul><li>Do not separate the newborn </li></ul></ul></ul></ul></ul><ul><ul><li>Baby – </li></ul></ul><ul><ul><ul><li>at birth – start Isoniazid & rifampicin </li></ul></ul></ul><ul><ul><li>- do PPD , CXR PPD (-) CXR (-) </li></ul></ul><ul><ul><li>Repeat PPD after 3 month: </li></ul></ul><ul><ul><li> PPD (-) CXR (-) mother completed TX BCG </li></ul></ul><ul><ul><ul><ul><li>PPD (+) CXR (-) continue INH & RIF for 6 more month </li></ul></ul></ul></ul><ul><ul><ul><ul><li>PPD (+) CXR (+) continue INH, RIF for 6 more months </li></ul></ul></ul></ul><ul><ul><ul><ul><li>+ PZA for 2 months </li></ul></ul></ul></ul>

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