Approach to respiratory distress in children.pptx

1. Approach to respiratory distress in children
Dr Habtamu semeneh
for 2nd yr anesthesiology students
4/3/2024 1

2. Outline
• Introduction
• Etiologies of RD in children
• Infectious causes of RD
• How to approach a child with RD
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3. Objective
• By the end of this session you are expected to know
– Basic anatomic difference of children Vs adult airway
– Common causes of RD in children and their basic management
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4. Definition
• RD is when breathing does not match the body’s metabolic
demand for oxygen due to failure of oxygenation and/or
ventilation.
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5. • Typically characterized by :-
– Signs of Increased work of breathing (such as tachypnea, use of
accessory muscles, and/or retractions)
– Head bobbing
– Nasal flaring
– Grunting
– Cyanosis
– Bradypnea
– Apnea
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6. Characteristics of breath sounds
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7. Common respiratory added
sounds
 Stridor is an abnormal,
high-pitched monophonic
sound, produced by
turbulent airflow caused by
the oscillation of a
narrowed airway.
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8. Peculiarities of airway in children
the cricoids ring is the narrowest part of the airway in the child; the
vocal cords are in the adult
large tongue
large omega shaped epiglottis
large head
short trachea, greater angle of carina; left main bronchus more
horizontal
the nasal passage which is approximately the same size as the cricoid
ring in children
 obligate nose breathers
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9. Child Vs adult
• Obstruction of airflow is affected by
– both airway size and
– compliance of the lung.
R =
1
𝑟4
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10. Etiology
• Immediately life-threatening
conditions
– Severe upper airway obstruction
– Tension pneumothorax
– Pulmonary embolism
– Cardiac tamponade
– Trauma
• Respiratory tract conditions
– Infections
– Asthma
– Anaphylaxis
– Foreign body aspiration(FBA)
– Airway anomalies
– Pulmonary edema
• Cardiovascular conditions
– Congenital heart disease
– Acute decompensated heart failure
– Pericarditis
– Cardiac arrhythmia
– Myocardial infarction
• Neurologic and muscle diseases
• Gastrointestinal conditions
• Metabolic and endocrine diseases
• Hematologic conditions
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11. • Infectious Respiratory tract conditions
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12. Classification of ARI
1.Acute upper respiratory tract infection
 common Cold
 Otitis media
 Pharyngtitis
 Retropharyngeal abscess
 peritonsillar abscess
 Sinusitis
 Epiglottis
Acute laryngotracheobronchitis( croup)
2. Acute lower respiratory tract infection
 Acute laryngotracheobronchitis( croup)
 Bronchiolitis
 Pneumonia
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13. Peritonsillar abscesses
• Patients with peritonsillar abscess exhibit tonsillar and peritonsillar swelling
and erythema with deviation of the uvula to the unaffected side.
• Most commonly caused by Group A streptococcus (GAS)
• The onset of symptoms is typically gradual.
• They will present with :-
– Local pain
– Sore throat
– Trismus
– Difficulty swallowing and
– Muffled ("hot potato") voice.
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14. Retropharyngeal abscesses
• The retropharyngeal space extends from the
base of the skull to the posterior mediastinum
• Retropharyngeal abscess often is a polymicrobial
infection.(GAS , S.aureus, respiratory anaerobes
like fusobacteria and prevotella).
• Occurs most commonly in children between the
ages of 2-4 yrs.
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15. Clinical manifestations
• Difficulty swallowing (dysphagia)
• Pain with swallowing (odynophagia)
• Drooling with decreased oral intake
• Neck stiffness
• Change in vocal quality (muffled, or
with a "hot potato" quality
[dysphonia]), gurgling sound, or
stertor
• Respiratory distress, stridor
develops as disease
progresses
• Neck swelling, mass, or
lymphadenopathy
• Trismus (in 20 % of pts)
• Chest pain (in patients with
mediastinal extension)
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16. Management
• Emergency surgical drainage
– In patients with severe airway compromise
– CT imaging showing abscesses that are large (≥2.5 cm2) and consistent
with a mature abscess (complete rim enhancement and scalloping).
• Initiate empiric intravenous antibiotic therapy as soon as
possible after surgical drainage or once the decision is made to
treat without surgical drainage.
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17. Acute Epiglottitis (Supraglottitis)
 Life threatening infection
 Age groups affected 2-7 yrs
Etiology
 most common cause
– H. influenzae type b(pre vaccination era)
– Now
• Streptococcus pyogenes
• S.pneumoniae
• S. aureus
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18. Clinical manifestation
Sudden onset
Rapidly progressing respiratory obstruction
Fever
Toxicity
sore throat
Voice/cry - muffled
Soft stridor
Drooling of saliva
Hyper extended neck
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19. This child's "tripod" positioning (trunk leaning forward, neck hyperextended,
chin thrust forward) is indicative of epiglottitis.
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20. Cont’d…
Most patients have concomitant bacteremia
occasionally, other infections are present, such as pneumonia,
cervical lymphadenitis, or otitis media.
Meningitis, arthritis, and other invasive infections with H. influenzae
type b are rarely found in conjunction with epiglottitis
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21. Diagnosis
Laryngoscopy
large, swollen cherry red epiglottis
Lateral roentgenogram of the upper airway
 swollen epiglottis – thumb sign
NB- avoid oral examination – risk of reflex laryngeal spasm
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22. Cherry red epiglottis Classic radiographs of a child who has epiglottitis
show the “thumb sign”
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23. Treatment
 Precaution
 Do not manipulate the throat
 Do not put patient in supine positions
 Is a medical emergency and warrants immediate treatment with an
artificial airway placed under controlled conditions
 Endotracheal intubation
 Tracheostomy
 Racemic epinephrine and corticosteroids are ineffective
 IV CAF/ cephalosporins for 7-10 days.
 Ceftriaxone and vancomycin in patients with MRSA
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24. Croup (laryngotracheobronchitis)
• Croup is a respiratory illness characterized by inspiratory stridor,
barking cough, and hoarseness.
– These symptoms result from inflammation in the larynx and subglottic
airway
• Is the most common infectious cause of upper airway
obstruction in children between 6 and 36 months of age.
• Usually has a viral etiology parainfluenza virus(most common) ,
RSV, SARS-CoV-2.
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25. Clinical manifestations
• Nasal congestion
• Coryza
• Fever
• Barky cough
• Hoarseness of voice
• Stridor
• Suprasternal, subcostal, and intercostal
retractions
• Breath sounds can be diminished
Croup: Anteroposterior radiograph with
"steeple sign"
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26. Severity assessment
• Mild croup (Westley croup score
≤2)
• Moderate croup (Westley croup
score 3 to 7)
• Severe croup (Westley croup score
≥8)
• Impending respiratory failure
(Westley croup score ≥12)
Components of westley croup score
• Level of consciousness
• Cyanosis
• Stridor
• Air entry
• Retractions
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27. Management
• Mild croup
– Home treatment
– Outpatient treatment
• Moderate/severe croup
– Corticosteroids
– Nebulized epinephrine
– Intubation
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28. Bacterial tracheitis
• Is an invasive infection of the soft tissues of the trachea.
• Most commonly Streptococcus or S. aureus including MRSA as a
secondary infection in a child with croup but may occur as a
primary infection.
• Bacterial tracheitis generally occurs during the first six years of
life.
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29. Clinical manifestations
• Fever (common but not universal)
• Stridor (inspiratory or biphasic)
• Cough (membranous exudates may be
expectorated)
• Respiratory distress
• Odynophagia or dysphagia
• Drooling is uncommon but may be
present
• Hoarseness or voice changes
Bacterial tracheitis: Lateral neck radiograph
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30. Management
• Airway management
• Fluid resuscitation (if needed)
• Empiric antibiotic therapy
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31. Bronchiolitis
• Is a lower respiratory tract infection that primarily affects the
small airways (bronchioles).
• Most commonly caused by respiratory syncytial virus.
• Typically affects children younger than 2 years of age.
• It is characterized by:-
– Several days of upper airway symptoms, most classically nasal
congestion and copious nasal secretions, followed by onset of lower
airway symptoms that include wheezing, rales, rhonchi, and cough.
• Peak severity of illness is usually between days 4 and 6 with
resolution of symptoms between days 10 and 14.
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32. Management
• Fluid management
• Nasal suctioning
• Supplemental oxygen
• Endotracheal intubation
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33. Pneumonia
• Defined as inflammation of the lung
parenchyma.
• The clinical presentation of
childhood pneumonia varies
depending upon:-
• The responsible pathogen
• The particular host and
• The severity
Global distribution of cause specific infectious
mortality among children younger than age 5 yr in
2015
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34. Cont’d…
• In Ethiopia it accounts for 28% of under 5 children deaths.
It is estimated that 65% of these pneumonia deaths could be prevented if appropriate
preventive and treatment interventions were applied at national scale.
• Treatments such as oral antibiotics, in addition to the effective prevention interventions (
breastfeeding and adequate complementary feeding.)
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35. Etiology
• Identifying organism a challenge: no reliable diagnostic method
• S. pneumoniae important bacterial cause regardless of age
• Mycoplasma pneumoniae and Chlamydia pneumoniae responsible
for mild to severe LRIs, particularly for age > 5 yr
• In younger patients: mostly respiratory viruses
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36. Etiologic agents for pneumonia is age dependent
Neonates (<1 month)
– Group B streptococcus,
– Escherichia coli, other gram-negative bacilli,
– Streptococcus pneumoniae, Haemophilus influenzae (type b,* nontypable)
1–3 month
Febrile pneumonia
Respiratory syncytial virus,
other respiratory viruses (parainfluenza viruses, influenza viruses, adenoviruses),
S. pneumoniae, H. influenzae (type b,nontypable)
Afebrile pneumonia Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma
urealyticum, cytomegalovirus
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37. 3–12 months
RSV, other respiratory virus
 S. pneumoniae, H. influenzae (type b, nontypable),
 C. trachomatis, Mycoplasma pneumoniae, group A streptococcus
2–5 yr
Respiratory viruses,
 S. pneumoniae, H. influenzae (type b, nontypable)
 M. pneumoniae, Chlamydophila pneumoniae
S. aureus, group A streptococcus
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38. Cont’d…
5–18 yr
 M. pneumoniae, S. pneumoniae, C. pneumoniae,
 H. influenzae (type b, nontypable),
 influenza viruses, adenoviruses, other respiratory viruses
≥18 yr
M. pneumoniae, S. pneumoniae, C. pneumoniae,
 H. influenzae (type b,nontypable),
 influenza viruses, adenoviruses, Legionella pneumophila
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39. Routes of infections
– Inhalation
– Aspiration
– Direct inoculation
– Blood borne
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40. Risk factors
– Lack of EBF
– Under nutrition
– Indoor pollution
– Low birth weight
– Crowding
– Viral respiratory tract infection
– Lack of immunization
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41. Pathology
 Lobar pneumonia
 Causes consolidation of large areas of the lung
Congestion
Red hepatization
Grey hepatization
Resolution
Bronchopneumonia
- Patchy consolidation
Interstitial
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42. Pathogenesis
Normally the lower respiratory tract is kept sterile by different defense
mechanisms include
Prevention of aspiration-epiglottal and cough reflex
Trapping of pulmonary secretion by mucus and ciliary action
Alveoli macrophage
Neutralization by specific and non-specific immune processes
Complement, opsonins, antibodies
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43. Defence of respiratory tract
• Mechanical
– Filtration
– Mucociliary clearance
– Reflex
• Innate defence
– airway antimicrobial factors
– Alveolar macrophages
– Neutrophils
• Adaptive defence
– Secretaory IgA
– IgG
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44. Clinical manifestations
On history
• Cough
• Fast breathing
• Fever
• Grunting
• Chest pain in older children
• Prior common cold like symptoms
 The last 3 are findings of a consolidated
lung
On physical examination
• Tachypnea
• Nasal flaring
• Intercostal, subcostal, and suprasternal
retractions, nasal flaring, and
use of accessory muscles
• Cyanosis
• Increased tactile fremitus
• Realtive Dullness on percussion
• Diminished breath sounds, scattered
crackles,BBS and rhonchi
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45. Viral pneumonia
• fever is usually present; temperatures are generally low
• Gradual onset symptoms
• Non-productive cough
• Other sx: headache, fatigue, myalgia, rhinorrhea, sore throat
• CXR: diffuse infiltrates
• WBC count can be normal or elevated but is usually not higher
than 20,000/mm3, with a lymphocyte predominance
• C-reactive proteins are normal or slight elevations.
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46. Bacterial pneumonia
• High grade fever
• Productive cough
• Chest pain
• Ill appearance
• elevated WBC count, in the range of 15,000-40,000/mm3, and a predominance of
granulocytes.
• A large pleural effusion, lobar consolidation,
• Elevated ESR, and C-reactive protein (CRP) level
Infants and young children less likely to have “classic”signs of pneumonia.
• Often: fever, tachypnea and subtle signs such as lethargy, irritability, vomiting,
diarrhea and poor feeding.
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47. Classification
I.Clinically
1. Community acquired pneumonia
 Typical/’’Classic’’ Pneumonia
-S. pneumonia(90% of bacterial pneumonia),
-HIB, S.aureus
 Atypical pneumonia-40-50%
-Afebrile, clear chest,CXR-extensive infiltration
-Viruses and mycoplasma
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48. Cont’d…
2. Hospital acquired pneumonia
- After 72 hours of admission or
- within 5 days of hospital discharge
 60% aerobic gram negative
- mostly enterobactericae (klebseilla,E.coli
and enterobacter)
-Less commonly-Pseudomonas
10-15% -S. aureus
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49. Cont’d…
II.Anatomic/Radiologic classification
1.Alveolar/Air space Pneumonia/ lobar
-Air brnchogram is characteristic
-Lobar type of consolidation
-S.pneumonia,Klebseilla,HIB
2.Bronchopneumonia
-Patchy and segmental distribution
-Staph.aureus,strep. pyogens,HIB
3.Interstitial pneumonia
 inflammatory process is more or less confined with in the wall that surrounds the alveoli and
bronchioles
 Reticular or reticulonodular infiltrates
 Patchy or homogenous opacity
 viral or mycoplasmal
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50. Cont’d…
III. Etiologic classification
Bacterial pneumonia
Viral pneumonia
Fungal pneumonia
Aspiration pneumonia
Others( lofflers syndrome , toxic chemicals ….)
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51. IV. Based on severity WHO
1. “pneumonia” with fast breathing and/or chest indrawing,
• which requires home therapy with oral amoxicillin, and
2. “severe pneumonia”,
• pneumonia with any general danger sign, which requires referral and
injectable therapy.
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52. Diagnosis
 Clinical
 CBC/Leukocytosis
 C- reactive protein
CXR
 Routine CXR is not necessary to confirm the diagnosis of suspected community-acquired
pneumonia (CAP) in children with mild, uncomplicated lower respiratory tract infection
(LRTI) who are well enough to be treated as outpatients.
 Indicated in
severe pneumonia
Confirmation of the diagnosis when clinical findings are inconclusive
when potential complications are suspected
Exclusion of alternate explanations for respiratory distress
Deteriorating or unresponsive to antimicrobial therapy
Recurrent pneumonia
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53. Cont’d…
CXR Findings
Viral pneumonia , afebrile pneumonia of infancy
 hyperinflation with bilateral interstitial infiltrates
 peribronchial cuffing
Bacterial pnuemonia
 Consolidation/ "round pneumonia"
 pneumatocele (S.aureus)
 Evidence of complication(pleural effusion……)
Bacteriology
 Pleural fluid analysis, cell count, gram stain, culture
 Blood culture
 Antigen detection tests
 Reliable DNA or RNA tests for the rapid detection of virus, ASO titer….
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54. Recurrent pneumonia
– is defined as 2 or more episodes in a single year or 3 or more episodes ever, with
radiographic clearing between occurrences.
– An underlying disorder should be considered if a child experiences recurrent bacterial
pneumonia
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55. Causes of recurrent pneumonia
Hereditary Disorders: Cystic fibrosis, Sickle cell disease
Disorders of Immunity: AIDS, agammaglobulinemia
Disorders of Cilia: Immotile cilia syndrome, Kartagener
syndrome
Anatomic Disorders: Sequestration, Foreign body,
Tracheoesophageal fistula ,Gastroesophageal
reflux, Bronchietasis
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56. Management
1.out patient
Antibiotics
Amoxycillin
Cotrimoxazole
Ampicillin
Augmentin
oral cephalosporin
 Antiphyretics
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57. 2.In patient management
 Age <6 mo
Sickle cell anemia with acute chest syndrome
Multiple lobe involvement
 Immunocompromised state
 Toxic appearance
Moderate to severe respiratory distress
Dehydration
Vomiting or inability to tolerate oral fluids or medications
No response to appropriate oral antibiotic therapy(failed OPD treatment)
Social factors (e.g., inability of caregivers to administer medications at
home or follow up appropriately)
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58. Supportive treatment
Bed rest
Nutritional supplementation ( maintainace fluid)
 oxygen supplementation
Antipyretics
Physiotherapy and breathing exercise
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59. Cont’d…
Neonate and imunocompromised
 Ampicillin +Gentamycin
Children
 Crystalline penicillin
If no improvement in 48hrs
Ceftriaxone
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60. 3.Treatment of complications
Empyema-Antibiotics 4-6wks
Chest tube drainage
Chest physiotherapy
Lung abscess-Broad spectrum antibiotics anaerobic coverage, 4-6wks
Surgery
chest physiotherapy
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61. Reasons for poor response
1. Complications, such as Empyema
2. Bacterial resistance
3. Nonbacterial etiologies such as viruses and aspiration of foreign
bodies or food
4. Bronchial obstruction from endobronchial lesions, foreign body,
or mucous plugs
5. Pre-existing diseases
6. Other noninfectious causes
NB:A repeat chest x-ray is the 1st step in determining the reason for
delay in response to treatment.
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62. Complications
Direct spread of bacterial infection within the thoracic cavity
parapneumonic effusion
Empyema/ pyopneumothorax
Pneumatocele
Lung abscess
pericarditis
Myocarditis
Hematologic spread
Septicemia
septic arthritis
Osteomylitis
Meningitis
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63. Parapneumonic effusion/ Empyema
Empyema is an accumulation of pus in the pleural space
Primary pulmonary infection(55%)
Ruptured lung abscess
Thoracic trauma and surgery(20%)
Mediastinitis/Esophageal perforation
Subdiaphragmatic infections(2%)
70% of empyemas occur in <2 years of age
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64. Epidemiology
Empyema is most frequently encountered in infants and preschool
children
It occurs in 5-10% of children with bacterial pneumonia and in up
to 86% of children with necrotizing pneumonia
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65. 4/3/2024
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66. Etiology
 Pneumonia is the most common cause 30-40 % develop parapneumonic effusion
Staph. Aureus(is most common in developing nations and Asia as well as in
post-traumatic empyema)
Strep.pneumoniae and strep pyogens (commonest in non traumatic cases)
Hemophillus influenzae
Less Common
Anaerobes
Enterobactericeae
 tuberculosis, fungi, and malignancy are less common causes
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67. Pathology
Empyema has 3 stages
 the exudative stage, fibrinous exudate forms on the pleural surfaces
 In the fibrinopurulent stage, fibrinous septa form, causing loculation of the
fluid and thickening of the parietal pleura
 the organizational stage, there is fibroblast proliferation; pockets of loculated
pus may develop into thick-walled abscess cavities or the lung may collapse and
become surrounded by a thick, inelastic envelope
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68. Clinical Manifestations
 The initial signs and symptoms are primarily those of bacterial pneumonia.
 Most patients are febrile, develop increased work of breathing or respiratory
distress, and often appear more ill.
 Physical findings
 Dullness may be found on percussion.
 Breath sounds are decreased or absent
 and there are a diminution in tactile fremitus
 a shift of the mediastinum away from the affected side
 crackles and rhonchi if extensive pneumonia is present
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69. Diagnosis
Radiographically, all pleural effusions appear similar, but the absence
of a shift of the fluid with a change of position indicates a loculated
empyema
 Septa may be confirmed by ultrasonography or CT
Pleural tab and analysis
Color
Cell count with differential
Gram stain
Culture
Chemistry
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70. 4/3/2024
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71. Treatment
Systemic antibiotics 4-6wks
Thoracentesis and possibly chest tube drainage with or without a
fibrinolytic agent(Streptokinase ,urokinase)
 Video-assisted thorascopic surgery (VATS), or open decortication
 Chest physiotherapy
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72. Covid - 19
• Coronavirus disease 2019 (COVID-19)
• Caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
• Although severe and fatal cases have been reported, most children appear
to have asymptomatic or nonsevere symptomatic infections
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73. commonly reported symptoms among children and
adolescents included
• Fever
• Cough
• Shortness of breath
• Myalgia
• Rhinorrhea
• Sore throat
• Headache
• Nausea/vomiting
• Abdominal pain
• Diarrhea
• Loss of smell or taste (in nonverbal children,
this may manifest as solid food aversion or
refusal)
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74. Management
• Supportive
– Provision of respiratory support
– Fluid management
– Antibiotics with indication
• Antiviral therapy
– For children with documented severe or critical COVID-19
– Mild or moderate disease and an underlying condition.
• Adjunctive therapy
– Corticosteroids
• Those who require mechanical ventilation or those who require supplemental oxygen
and have risk factors for disease progression.
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75. Asthma
Asthma is a chronic
inflammatory condition
of the lung airways
characterized by :-
Recurrent airway obstruction
Bronchial hyper responsiveness and
Airway inflammation
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76. 4/3/2024 77

77. Evaluation of Asthma in Children
• The diagnosis of asthma in young children is based on
– Individual history
– Physical examination and
– Risk factors
– Their response to treatment
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78. History
• Night or early morning Cough
• Breathlessness
• Chest tightness
• Prior Hospitalization
• Triggers
• Family history
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79. Physical Findings
• Tachypnea
• Increased work of breathing
• Wheezing
• Prolonged Exhalation phase
• Decreased breath sound
• Rhonchi and Crackles
• No Wheezing ??
• Injected conjunctiva
• Nasal congestion
• Eczema
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80. Early childhood Risk factors for persistent asthma
• Parent asthma
• Eczema
• Inhalant allergen sensitization
• Allergic rhinitis
• wheezing apart from colds
• ≥4% peripheral blood eosinophils
• Food allergen sensitization
• Pneumonia
• Bronchiolitis
• Low birth weight
• Formula feeding
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81. Long term management
Acute exacerbations
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82. Long Term Management
• Key Components
1. Regular Assessment and monitoring
2. Patient Education
3. Control of factors contributing to Asthma Severity
4. Asthma Pharmacotherapy
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83. Management of Asthma Exacerbations
Goal of Management
• Correction of Hypoxemia
• Rapid improvement of airflow obstruction
• prevention of progression or recurrence of symptoms
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84. Mild Exacerbation
• Outpatient management
• B2 Agonist
• Via MDI-S 2-8 puffs q 20 min for 3 doses then q 1-4 hr as needed
• Corticosteroid ???
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85. Moderate
• Administer oxygen
• B2 Agonist
• Salbutamol puff 2-8 puffs q 20min for 1hr
• Corticosteroid (short course)
– Prednisolone 1-2mg/kg BID for 3-7 days
– Dexamethasone 0.6mg/kg oral, IV or IM
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86. Severe
• Supplemental Oxygen
• B2 Agonist
• Corticosteroid
• Ipratropium Bromide
• Epinephrine 0.01 mL/kg of a 1 mg/mL solution; maximum dose of 0.4 mg
or 0.4 mL) may repeat q 15 min 3x
• Magnesium sulfate 25-75mg/kg in NS over 20 min
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87. Monitoring
BP RR PR T* SPo2 Mentation Wheezing Accessory
muscle use
Air
entry
++++++++++++++++
Every 20-30 minutes for the first one hour then depending on the
patients response and severity
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88. Foreign body aspiration
• Choking is a leading cause of morbidity and mortality among
children, especially those younger than 4 yr of age.
• Nuts, seeds, hot dogs, hard candy, gum, bones, and raw fruits and
vegetables are the most frequently aspirated food items.
• Globular, compressible, or round objects such as hot dogs, grapes,
nuts, balloons, marshmallows, meats, and candies are particularly
hazardous due to their ability to completely occlude the airway.
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89. Risk factor
• Underdeveloped ability to swallow food
• Infants and toddlers often use their mouths to explore their surroundings
• children generally are more likely to be distracted, playing, or ambulatory
while eating.
• Young children are more likely to experience significant blockage by small
foreign bodies due to their smaller airway diameter
• Weak expiratory effort to dislodge after aspiration
4/3/2024 90

90. • There are typically 3 stages of symptoms that result from aspiration of
an object into the airway:-
1. Initial event: Paroxysms of coughing, choking, gagging, and possibly
airway obstruction occur immediately after aspiration of the foreign
body.
2. Asymptomatic interval: The foreign body becomes lodged, reflexes
fatigue, and the immediate irritating symptoms subside.
3. Complications: Obstruction, erosion, or infection develops, which
again directs attention to the presence of a foreign body .
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91. Management
• Depends on the level where the FB is present
– Laryngeal(2-11%)
– Tracheal(3-12%)
– Bronchial(80-90%,most common)
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92. Question
• A 9 month girl and her older brother have been playing in the emergency
department with an old bead necklace, suddenly the child is brought to
you by one of the nurses, and the child is choking. What do you do?
• A 3 year old boy is carried into the outpatient department in his father's
arms. He is pale, floppy and having difficulty breathing. His father says he
has been unwell and coughing for 3 days. Weight 14 kg. He breathes fast
with heavy severe chest indrawing. The airway is patent. He is alert. How
do you triage this child? What do you do?

93. Assess if it is an airway or breathing problem
• Child not breathing or gasping
• Signs of airway obstruction
• Blue child (centrally cyanosis)
• Signs of severe respiratory distress
94

94. ``
95

95. Assessment of the Airway
1. Look
2. Listen
3. Feel
96

96. Management to open the airway
Simple techniques to open the airway
Open the airway
Clear the airway
Remove foreign body obstructing the airway
Use airway adjuncts
Avoid unnecessary agitation which worsens the obstruction
97

97. Maneuvers to open the airway
• Head tilt–chin lift(non-trauma)
• Jaw trust(for trauma)
98

98. Clearing the airway
• Clearance of liquid and particulate material from mouth and
nose.
• Avoid deep suctioning
• Avoid suctioning in neck
trauma
99

99. Insertion of an Oropharyngeal Airway
• Oro pharyngeal airway used for unconscious patient to improve
airway opening.
100

100. Management of foreign body aspiration (a choking
child)
For infants
• Give 5 blows to infant’s back.
• If persists, turn over and give 5
chest thrusts
For children
• Give 5 blows to the child’s back
• If persists, Heimlich manoeuver 5 times
101

101. Advanced intervention
1. Endotracheal intubation
2. Removal of foreign body with direct visualization by
laryngoscope
3. Application of positive airway pressure (CPAP)
4. Cricothyroidotomy
102

102. Assessment of breathing
Is the Child Breathing?
LOOK
• Chest movement, signs of respiratory distress, central cyanosis
LISTEN
• breath sounds(normal or noisy)
FEEL
• Movement of air through nose or mouth of the child
103

103. Management of breathing problem
1. Bag mask ventilation
2. Give oxygen by different ways depending on the child condition.
3. Thoracentesis and or tube thoracostomy
104

104. Ventilate with Bag and Mask
• If the child is not breathing or gasping, ventilate with a self
inflating bag and mask.
105

105. Give oxygen
• Children with cyanosis
• Severely ill children with shock, acidosis or other problems may
also benefit from oxygen
Sources of oxygen to treat hypoxemia
• Oxygen concentrators
• Oxygen cylinders
106

106. Oxygen Delivery
1. Nasal prongs
2. Nasal catheter
3. Face Mask
107

107. Question
• A 9 month girl and her older brother have been playing in the emergency
department with an old bead necklace, suddenly the child is brought to
you by one of the nurses, and the child is choking. What do you do?
• A 3 year old boy is carried into the outpatient department in his father's
arms. He is pale, floppy and having difficulty breathing. His father says he
has been unwell and coughing for 3 days. Weight 14 kg. He breathes fast
with heavy severe chest indrawing. The airway is patent. He is alert. How
do you triage this child? What do you do?

108. Ameseginalew
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