Respiratory
Disease In
Childhood
Nick Connolly
Paediatric SpR
NHS Tayside
Respiratory problems in
children
 Neonatal respiratory problems
 Respiratory problems in older children
 Chronic
 Acute
Scenario
An infant born at 30 weeks
gestation develops respiratory
distress at age 2 hours
Respiratory Distress Syndrome
 Relative Surfactant deficiency
 1% all births
 Predominantly in preterm – inverse relationship
with gestation
Surfactant
 Phospholipid
 Apoproteins
 Secreted at 30-32/40
 Lack of surfactant results in atelectasis and
impairment of gas exchange
 Production stimulated by steroids
Incidence of RDS relative to gestational age
100
90
80
70
60
50
40
30
20
10
0
% with clinical RDS
26
28
30 32 34 36
Gestational Age
38
40
Further problems
 Ventilated
 Sudden deterioration requiring increased oxygen
 No breath sounds on the right side of chest
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
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
Scenario
New born full-term infant with
severe breathing difficulty after
birth
?Dextrocardia
Diaphragmatic Hernia
 Incidence:1/2400
 Associated pulmonary hypoplasia
 Commonest- Posterolateral (Bochdalek), left-sided
 Avoid bag-mask IPPV?
 Respiratory support
 Surgical
Older Children
Examination
 Weight(length/height)..plotted!
 ?clubbing
 Chest shape
 Auscultation
Breathing tests
Chronic problems
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
Cystic Fibrosis
 Autosomal recessive
 Carrier incidence roughly 1 in 25 people
 Mutations in the CFTR gene
 Multisystem disorder
 Respiratory infections are prominent
Differential diagnosis
 Immune deficiency
 Ciliary dyskinesia
 Asthma
 Kartagener’s/ immotile cilia syndrome- rare
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
Cystic Fibrosis Team
 Clinician
 Specialist nurse
 Clinical psychologist
 Social worker
 Physiotherapist
 Dietician
A 7-year child presents to your
clinic with a 3-month history of
cough worse at night or during
active play
Diagnosis: ASTHMA
Asthma – Diagnosis in Children
SIGN 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
Asthma – Diagnosis in Children
SIGN 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
Asthma – Diagnosis in Children
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
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
Acute problems
Acute asthma
Cough and wheeze worsening
over hours or days
Treatment
 Oxygen
 Nebulised bronchodilator
 Oral prednisolone
 IV salbutamol
 IV aminophylline
 IV magnesium
 Ventilatory support
Scenario
 6 week old presented with increased work of
breathing and possible apnoes
 URTI symptoms over last 2 days
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
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
Pneumonia
 Neonates: GBS, E.coli, Klebsiella, Staph aureus
 Infants: Strep pneumoniae, Chlamydia
 School age: Strep pneumoniae, Staph aureus, Gr A
strep, Bordetella, Mycoplasma, Legionella
Scenario
A 2-year old child presenting with
barking cough and difficulty in
breathing of sudden onset
Differential Diagnosis
 Inhaled foreign body
 Laryngomalacia
 Epiglottitis and bacterial tracheitis
 Allergy
 Croup
Croup
 Viral laryngotracheobronchitis
 Stridor, barking cough
 Treatment is oral steroid to reduce inflammation
Scenario
9 month old infant from
developing country with
irritability, neck rigidity, afebrile
Pulmonary Tuberculosis
 Mycobacterium tuberculosis
 Notifiable disease
 1/3 of World Population!
 Droplet infection
 Prevention(of severity): BCG
 Drug treatment:
2 mths- Isoniazid, Rifampicin,
Pyrazinamide
4 mths- Isoniazid, Rifampicin
Common respiratory problems
in children
 Infant respiratory distress syndrome
 CLD
 Congenital diaphragmatic hernia
 Cystic fibrosis
 Asthma
 Bronchiolitis
 Childhood pneumonias
 Croup
 Tuberculosis
FINISHED