The document discusses pediatric respiratory and cardiac diseases. For respiratory diseases, it covers common illnesses like upper respiratory infections, laryngitis, bronchitis, pneumonia and asthma. It also discusses less common conditions like epiglottitis, croup, sinusitis and tuberculosis. For cardiac diseases, it begins with an overview of fetal, transitional and pediatric circulation. It then covers congenital heart defects categorized as left-to-right shunts, right-to-left shunts, and obstructive lesions. Physical exam findings and management strategies are also summarized. The document provides detailed information on evaluation and treatment of various pediatric respiratory and cardiac conditions.

1. PEDIATRIC RESPIRATORY &
CARDIAC DISEASES
Dr Bodhisatwa Choudhuri
MBBS, MD(Med), MEM(GWU), MRCEM(UK), Dip. Rheumatology(UK)
Consultant & HOD, Emergency & Critical Care Dept, ILS Hospital, Howrah
Joint Secretary – SEMI West Bengal Chapter

2. RESPIRATORY DISEASES
• Upper respiratory tract infection
• Laryngeal/tracheal infection
• Bronchitis
• Brochiolitis
• Pneumonia

3. ACUTE NASOPHARYNGITIS
• Common colds
• Average of 3-8 URI/year
• Rhinovirus
• First 2 yrs. of life
• Fever, irritability, sneezing
• Differential dx: foreign body obstruction, allergic rhinitis
• Otitis media - most common complication

4. ACUTE PHARYNGITIS
• “Tonsillitis, Tonsillopharyngitis”
• Group A b-hemolytic streptococcus
• 4 – 7 yrs. Old
• Headache, abdominal pain, vomiting, petechial mottling of soft
palate (strep)
• Throat swab for strep antigen, throat culture
• Otitis media - most common complication
• Penicillin/Amoxicillin – drug of choice for strep

5. RETROPHARYNGEAL ABSCESS
• Complication of Bacterial pharyngitis
• Most frequent in children < 3 yr of age
• Grp A hemolytic strep, oral anaerobes, staph aureus
• Fever, difficulty of swallowing, drooling
• Bulging of posterior pharyngeal wall
• Complication: aspiration of pus
• Meds: amoxicillin, clindamycin, ampicillin-sulbactam

6. SINUSITIS
• Maxillary & ethmoid – anatomically present in utero
• Frontal – develop by age of 1-2 yr
• Frontal & Sphenoid – radiologically present only at 5-6 yrs of age
• Strep pneumoniae, moraxella catarrhalis, H. influenzae
• Cough, nasal discharge – most common symptoms
• Fever, peri orbital edema, facial pain
• (+) air fluid level & opacification
• Complications: meningitis, subdural abscess

7. EPIGLOTTITIS
• “supraglottitis”
• H. influenza b
• 2 – 7 yrs old
• Severe airway obstruction
 death
• Inspiratory stridor
• “tripod sign”
• Cherry red epiglottis
• Keep airway patent
• Meds: cephalosporin

8. CROUP
• “Laryngotracheobronchitis”
• Fever, brassy cough, inspiratory stridor
• Occurs in young children
• Mx: steam inhalation, dexamethasone, racemic
epinephrine
• Contraindicated: opiates or sedatives

10. LARYNGITIS
• Acute Spasmodic Laryngitis
• Similar to LTB with absence of history of URI
• Afebrile, barking cough
• Acute Infective Laryngitis
• Caused by viruses
• Subglottic area – principal site of obstruction
• Loss of voice

11. BACTERIAL TRACHEITIS
• Life threatening airway obstruction
• S. aureus
• < 3 yrs old
• Follows an apparent viral infection, measles
• As complication of intubation
• Direct laryngoscopy – pus
• Mx: intubation/ tracheostomy, antibiotics

12. ACUTE BRONCHITIS
•Gradual onset
•Preceded by URTI
•Fever, conjunctiva injection, rhinitis, dry hacking,
non-productive cough
•Chest pain, wheezing, rhonchi
•Mostly viral, no role of antibiotics

13. BRONCHIOLITIS
• Respiratory syncytial virus – 50%
• Occurs during the 1st 2 yrs of life (peak – 6 month of age)
• “ball valve” type of obstruction  hypoxemia  V/Q mismatch  respiratory
failure
• Critical phase  first 48 – 72 hrs
• Fever, Cough, wheezing, dyspnea, Subcostal and intercostals recession
• CXR – increase AP diameter, hyperinflation
• MX: oxygen, ribavirin
• Most infants recover from the acute infection within two weeks
• Nearly half will have recurrent episodes of cough and wheeze over the next 3-
5 years

14. BRONCHIOLITIS OBLITERANS
• Progressive airways obstruction
• Inflammation & granulations tissue formation of small
airways
• Associated with adenovirus infection
• Common complications of lung transplant
• May be delayed by corticosteroids

15. PNEUMONIA
• Causative agents: bacteria, virus, mycoplasma, aspiration
• Bacterial Pneumonia
• Children > 2 months of age
• Most common microorganisms: S. pneumoniae, H. influenzae
• Most common symptoms: fever, cough, dyspnea
• Children < 2 months old
• Most common microorganisms: Group b strep, E. coli, Listeria
• +/- fever
• Tachypnea - most reliable sign
• Children > 5 years of age
• Most common microorganisms: Mycoplasma, Strep pneumoniae, H.
influenzae, S. aureus

16. Pneumococcal
pneumonia
• 90% cases
• Lobar involvement
• CXR: lobar
consolidation
H. Influenzae
pneumonia
• Insidious onset
• Preceded by URTI
• Nosocomial
infection
• no characteristics
clinical /
radiological
patterns
Klebsiella
pneumonia
• Thick-rusty sputum
• Bulging of fissures
• Pulmonary abscess
& cavitations

17. Staphylococcal pneumonia
• Occurs in young infants
• Associated with septicemia, skin infections, measles
• Serious, rapid progressive course of illness
• Extensive bilateral lung involvement
• CXR: nodular infiltrates, multiple abscesses, empyema, pneumothorax
• Meds: penicillinase-resistant penicillin
Pseudomonas pneumonia
• Immunocompromised, debilitating patients
• Prolonged mechanical ventilatory support
• HIV
• CXR: presence of necrosis

18. Staph. Pneumonia

19. SUMMARY - PNEUMONIA

20. TUBERCULOSIS IN CHILDREN
• Etiology: mycobacterium tuberculosis
• Droplet’s inhalation  lungs
• Incubation period: 2 - 10 weeks
• Mantoux test
• Positive PPD
• > 10 mm induration
• Children < 5 yr old
• BCG immunized children
• > 5 mm induration
• Children > 5 yr old
• Non-BCG vaccinated children
• T/T: ATD – Cat-I (HRZE)2/(HRE)4

21. Miliary TB

22. NON-INFECTIOUS DISORDERS OF
THE RESPIRATORY TRACT
• Congenital
• Nasal hypoplasia, High arch palate,
Choanal atresia
• Laryngomalacia, Tracheomalacia
• Congenital Central Hypoventilation
Syndrome
• Congenital lung anomalies
• Lung agenesis, Lung hypoplasia
• Pulmonary Sequestration
• Bronchogenic Cysts
• Congenital Cystic Adenomatoid Malformation
(CCAM)
• Congenital Lobar Emphysema
• Acquired
• Allergic rhinitis
• Epistaxis
• FB obstruction/
aspiration
• Nasal polyps
• Nasal septal deviation
/ perforation

23. ASTHMA
• Most common chronic ds of childhood – commonest cause of
school absences
• Increased airway resistance, decreased flow rate, bronchospasm,
increased WOB, progressive decrease in TV
• Trigger: Exercise, allergen, infections, weather changes
• Non-productive cough, wheezing, SOB
• Rx: Inhaled steroid first line of drug
• Combination of bronchodilators & anti-inflammatories,
anticholinergics, mast cell stabilizers, short course of systemic
corticosteroids

24. PAEDIATRIC CARDIAC
DISEASES

25. FETAL CIRCULATION
• For the fetus the placenta is the oxygenator so the lungs do little
work
• RV & LV contribute equally to the systemic circulation and pump
against similar resistance
• Shunts are necessary for survival
• ductus venosus (bypasses liver)
• foramen ovale (R→L atrial level shunt)
• ductus arteriosus (R→L arterial level shunt)

26. TRANSITIONAL CIRCULATION
• With first few breaths lungs expand and serve as the
oxygenator (and the placenta is removed from the circuit)
• Foramen ovale functionally closes
• Ductus arteriosus usually closes within first 1-2 days

27. NEONATAL CIRCULATION
• RV pumps to pulmonary circulation and LV pumps to
systemic circulation
• Pulmonary resistance (PVR) is high; so initially RV pressure
~ LV pressure
• By 6 weeks pulmonary resistance drops and LV becomes
dominant

28. NORMAL PEDIATRIC CIRCULATION
•LV pressure is 4-5 x RV pressure (this is feasible
since RV pumps against lower resistance than LV)
•RV is more compliant chamber than LV

29. CONGENITAL HEART DISEASE (CHD)
• Occurs in 0.5-1% of all live births
• Simple way to classify is:
• LR shunts
• Cyanotic CHD (RL shunts)
• Obstructive lesions
• VSD – Commonest CHD (25-30%)

30. LR SHUNTS (“ACYANOTIC” CHD)
• Defects
1. VSD
2. PDA
3. ASD
4. AVSD (or complete atrioventricular canal/ endocardial
cushion defect))
• May not be apparent in neonate due to high PVR (i.e.-
bidirectional shunt)

31. LR SHUNTS – GENERAL POINTS
PDA & VSD
• Presents in infancy with heart
failure, murmur, and poor growth
• Left heart enlargement (LHE)
• Transmits flow and pressure
ASD
• Presents in childhood with murmur
or exercise intolerance (AVSD or 1°
ASD presents earlier)
• Right heart enlargement (RHE)
• Transmits flow only
AVSD can present as either depending on size of ASD & VSD component

32. VSD ASD

33. CHARACTERISTICS OF PATIENTS
WITH LR SHUNTS
• Absence of cyanosis
• Frequent chest infections - Due to decreased lung compliance which leads to
frequent respiratory tract infections
• Precordial bulge
• Excessive sweating - Tendency for CCF
• Failure to thrive - due to poor oxygen saturation in the growing tissues,
persistent heart failure, and frequent respiratory infections with
undernutrition
• Cardiomegaly
• Shunt & flow murmurs
• Plethoric lung fields

34. EISENMENGER’S SYNDROME
• A long standing L→R shunt will eventually cause
irreversible pulmonary vascular disease
• This occurs sooner in unrepaired VSDs and PDAs (vs an
ASD) because of the high pressure
• Once the PVR gets very high the shunt reverses (i.e.- now
R→L) and the patient becomes cyanotic

35. SUMMARY LR SHUNT

36. R→L SHUNTS (CYANOTIC CHD)
↑ PBF
• Truncus arteriosus
• Total anomalous pulm. venous
return (TAPVR)
• Transposition of the great arteries
(TGA)
• Single Ventricle
↓ PBF
• Tetralogy of Fallot (VSD, PS,
Overriding aorta, RVH)
• Tricuspid atresia
• Pulmonary atresia
• Ebstein’s anomaly
• TAPVR with obstruction
• “Blue blood bypasses the lungs”
• Degree of cyanosis varies
• Classify based on pulmonary blood flow (PBF)

37. RL SHUNTS – GENERAL POINTS
↑ PBF
• Presents more often with heart
failure (except TGA)
• Pulmonary congestion worsens
as neonatal PVR lowers
• Sats can be 93-94% if there is
high PBF
↓ PBF
• Presents more often with
cyanosis
• Oligemic lung fields
• Closure of PDA may worsen
cyanosis

38. CHARACTERISTICS OF CYANOTIC
PATIENTS
• Cyanosis, SOB on exertion (feeding)
• Hyper-cyanotic/Tet spells : in TOF
• caused by right-sided outflow tract obstruction leading to RL shunting
through a VSD
• periods of increasing cyanosis associated with inconsolable crying , fast
breathing and irritability (may lead to unconsciousness , anoxic seizures,
MI, cerebrovascular accidents, death)
• T/t: 100% O2 via NRBM, calming the child, knee-chest position, Morphine
• Clubbing, Polycythemia, Murmurs, Failure to thrive

39. TA TOF

40. DIFFERENT AMOUNTS OF PBF
TA TOF

41. OBSTRUCTIVE LESIONS
Ductal Dependent
1. Critical PS/AS
2. Critical CoA
3. HLHS
• Without PDA there is no blood flow
to lower extremities & abdomen
• Presents in CV shock at 2-3 days of
age when PDA closes
• +/- cyanosis
• Needs PGE1
Non-Ductal Dependent
1. Mild-moderate AS
2. Mild-moderate CoA
3. Mild-moderate PS
• Presents in older child with murmur,
exercise intolerance, or HTN (in
CoA)
• Not cyanotic

42. CHARACTERISTICS OF PATIENTS
WITH OBSTRUCTIVE LESIONS
• Absence of cyanosis or frequent chest infections
• Normal precordial shape
• Forcible/heaving cardiac impulse, without cardiomegaly
• Delayed S2
• Ejection systolic murmur, with thrill
• Absence of diastolic murmurs
• Normal sized heart with normal pulmonary vascularity
• Ventricular hypertrophy on ECG
• Chest pain - severe aortic stenosis lead to myocardial ischemia

43. SUMMARY OBSTRUCTIVE LESIONS

44. PHYSICAL EXAM
• Inspection and palpation
• Cardiac cyanosis must be central
• Differential cyanosis = R→L PDA shunt
• Differential edema/congestion implies obstruction of SVC or IVC
• Increased precordial activity
• Displaced apex beat
• RV heave = RV hypertension
• Lungs: Respiratory rate and work of breathing, Oxygen saturations
• Abdominal exam: Liver size
• Extremities: Perfusion, Edema, Clubbing

45. Pulses
• Differential pulses (weak LE)
= CoA
• Bounding pulse = run-off
lesions (L→R PDA shunt, AI,
BT shunt)
• Weak pulse = cardiogenic
shock or CoA
• Pulsus paradoxus is an
exaggerated SBP drop with
inspiration → tamponade or
bad asthma
• Pulsus alternans – altering
pulse strength → LV
mechanical dysfunction
Heart sounds
• Ejection click = AS or PS
• Mid-systolic click = MVP
• Loud S2 = Pulmonary HTN
• Single S2 = one semilunar
valve (truncus), anterior aorta
(TGA), pulmonary HTN
• Fixed, split S2 = ASD, PS
• Gallop (S3) – may be due to
cardiac dysfunction/ volume
overload
• Muffled heart sounds and/or
a rub = pericardial effusion
― tamponade
Murmurs
• Systolic Ejection Murmur
(SEM) = turbulence across a
semilunar valve
• Holosystolic murmur =
turbulence begins with
systole (VSD, MR)
• Continuous murmur =
pressure difference in systole
and diastole (PDA, BT shunt)

46. MANAGEMENT OF CHD
• Early identification of problem
• Supportive management:
1. Treatment of heart failure
2. Prevent frequent RTIs
3. Maintain required weight , Hb
4. Infective endocarditis prophylaxis
5. Regular follow-ups
• Surgical management

47. SYNDROME ASSOCIATIONS
• Down – AV canal and VSD
• Turner – CoA, AS
• Trisomies 13 and 18 – VSD, PDA
• Fetal alcohol – L→R shunts, ToF
• CHARGE – conotruncal (ToF, truncus)

48. HEREDITARY DISEASES
• Marfan (AD)– aortic root aneurysm ― dissection, MVP, MR, AI
• HCM (AD) – outflow tract obstruction, arrhythmias
• Noonan (AD) – HCM, PS
• DMD/BMD (X-link) – DCM (>12 y.o.)
• Williams (AD) – supravalvar AS
• Tuberous sclerosis – rhabdomyoma
• Romano-Ward – AD LQTS
• Jervell & Lange-Nielsen – AR LQTS & deafness

49. KAWASAKI DISEASE (KD)
• Now the #1 cause of acquired heart disease
• A systemic vasculitis (etiology-unknown)
• Tests – CBC, CMP, CRP, ESR, EKG, ECHO
• Rx – IVIG at 2g/kg and high-dose ASA
• Prognosis – Coronary artery dilatation in 15-25% w/o IVIG
and 4% w/ IVIG (if given within 10 days of fever onset).
Risk of coronary thrombosis

50. RHEUMATIC FEVER
• A post-infectious connective tissue disease
• Follows GAS pharyngitis by 3 weeks
• Injury by GAS antibodies cross-reacting with tissue
• Dx – JONES criteria (major and minor)
• Tests – Throat Cx, ASO titer, CRP, ESR, EKG, +/- ECHO
• Rx – Penicillin x 10 days and high-dose ASA or steroids
• 2° Prophylaxis – daily PO Penicillin or monthly IM Penicillin

51. TAKE HOME MESSAGE
• Pulse oximetry – the most important diagnostic tool in ED – effective in screening
for congenital heart disease in asymptomatic newborns
• Chest X-Ray – An important tool to diagnose respiratory/cardiac ds
• Pre discharge 4 extremity BP check is standard of practice to r/o CoA
• Early referral
• Involve pediatric cardiologist immediately : don’t wait
• Right diagnosis with a good echo
• Keep prostin available
• Don’t hesitate to call for help if in doubt

52. THANKS!
Do you have any questions?
bodhi.doc@gmail.com
+91 9830636315
www.drbodhisatwachoudhuri.com