Infection Diseases of Respiratory System in Children

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Infection Diseases of Respiratory System in
Children

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Introduction

• High Morbidity Rate
• High Mortality Rate

Acute and Chronic Infection Rheumatic
Disease Pleural Disease Foreign Body of
Airway Neoplasm Congenital Anomalies
Each year, respiratory infection diseases cause
about 15 million deaths among children younger
than age 5 year through the world. This is a
significant cause of mortality in childhood.
Pediatric pulmonary infection accounts for about
63.89 of all hospitalizations of children, in
which 44.6 percent are pneumonia.
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Anatomy and Physiology
Venting, Warming, Humidification and
conditioning
Upper respiratory tract nose, paranasal
sinuses pharynx, eustachian tube,
epiglottis, larynx
Cricoid cartilage
Lower respiratory tract trachea, bronchi,
bronchioles, alveolus
ventilation
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Anatomy and Physiology
Upper respiratory tract
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Anatomy and Physiology
Lower respiratory tract

• Narrowed airway
• Soft mucous menbrane
• More vascular
• Softer and more compliant
• pulmonary alveoli
• sIgA on Respiratory Mucosa
• alveolar surfactant

Small amounts
Clinical significance Easy to become hyperemia,
edema, and congestion which will
induce infection Complication Pulmonary
emphysema and atelectasis
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Anatomy and Physiology

• The younger the child
• The quicker the frequency
• The less regular the rhythm

Vital capacity (VC) Tidal volume Total lung
capacity (TLC)
Small
Respiratory frequency and rhythm The
respiratory frequency is inversely related to age
. ? neonate 4050 bpm612mo 30-35 bpm
1-3 yr 2530 bpm49 yr 20-25 bpm
8-14 yr 1820 bpm? (2) Some young infants
present with irregular rhythm or apnea due to
immature respiratory center.
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Anatomy and Physiology

• Thoracic cage
• The thorax is barrel shaped. The ribs are in
  horrizontal position which are almost
  perpendicular to the spinal column. The location
  of diaphragm is oppositely superior, which make
  the size of thoracic cavity decrease, and the
  size of lung increase.
• Respiratory immune function
• The specific and nonspecific immune function
  are poor.

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Acute Upper Respiratory Infection

• Acute Upper Respiratory Tract Infection
• AURI
• commonly called common cold

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Introduction

• The common cold is the most common pediatric
  disease and accounts for 80-90 proportion of
  visit to clinic.
• Local infection may spread to nearby organs and
  tissues which will likely to cause otitis media,
  conjunctivitis, lymphadenitis, lymphadenitis and
  pneumonia.
• Bronchial asthma, nephritis, myocarditis, measles
  and pertussis may also follow AURI

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Etiology
Rhinovirus Echo virus Coxsackievirus Parainfluenza
Influenza Adenovirus RSV(Respiratory Syncytial
Virus)

• 90 of AURI are caused by viral infection

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Bacteria
Pneumococcus Moraxelle catarrhalis
Haemophilus influenzae Staphylococcus aureus
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Others
Mycoplasma Chlamydia Other Microorganisms
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Clinical Manifestation
Mild symptom Nasal congestion, rhinorrhea,
sneezing, sore throat Severe symptom High
fever, convulsion, anorexia,frequency cough
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Symptoms of URI in children of different ages
lt 3 mo Infants Adolescents
Systemic symptom Usually mild Low grade fever Usually severe High fever Convulsion Irritability Usually mild Low grade fever
Respiratory Symptoms Nasal congestion Dyspnea Absent or mild or severe Nasal congestion Rhinorrhea Sneezing Sore throat
Gastrointestinal Symptoms Diarrhea Vomiting Diarrhea Vomiting Anorexia Abdominal Pain
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Physical Sign

• The pharynx is red
• Retropharyngeal folliculosis
• Erythematous enlarged tonsils
• Enlarged lymph nodes
• Enterovirus illnesses may be associated with a
  wide variety of skin rashes

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Two Special Type

• Herpangina
• Coxsackievirus A
• Most often occurs in summer and autumn
• More often in infants(0-3 yr of age)
• Characterized by sudden onset of fever, sore
  throat and dysphagia
• Characteristic lesions, present on the posterior
  pharynx, are discrete vesicles and ulcers
• Duration of illness is usually 7 days

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Pharyngoconjunctival Fever

• Occurs typically with type 3,7 adenovirus
• Most often occurs in spring and summer
• Children (gt3 yr ) more often affected
• Features include
• A high temperature that lasts 45 days,
  pharyngitis, conjunctivitis, cervical
  lymphadenopathy, and rhinitis.
• Duration of illness is usually 1-2 weeks

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Complication

• Otitis media
• Cervical lymphadenitis
• Bronchitis
• Pneumonia
• Septicemia

Viral Infection ? Viral Myocarditis
Viral Encephalitis Bacterial Infections(streptococ
cus)) ? Acute Nephritis Rheumatic Fever
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Diagnosis
Clinical manifestations Symptoms and sighs
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Differential diagnosis

• The differential diagnosis of the URl includes
  other acute infectious disease.
• In patient with febrile convulsion, central
  nervous system Infections should also considered.
• Patients with abdominal pain may have acute
  abdomen.

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Difference Between Mesenteric Lymphadenitis and
Acute appendicitis
Clinical Manifestation Mesenteric lymphadenitis Acute appendicitis
Symptom of URI exist absent
Fever and Abdominal Pain 1st present with fever Follow pain (mild) 1st present with pain (severe) Follow Low grade fever
Abdomen signs Diffuse tenderness No rebound tenderness and guarding Progressive localized abdominal tenderness With rebound tenderness and guarding
Blood routine WBC is usually normal or elevated WBC is elevated higher level of neutrophils
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Prophylaxis

• Increase outdoor activities.
• Improve physical fitness.
• Enhance immunity function.
• Patients in collective institutions
• should be isolated.

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Treatment

• General treatment
• Etiological treatment
• Anti-virusRibavirin
• Avoid the abuse of antibiotics
• Symptomatic treatment
• Severe nasal obstruction
• Irritability-restlessness
• High fever
• Pharyngeal portion ulcer
• Conjunctivitis

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Summary

• Upper respiratory infection is the most common
  disease in childhood
• most of which are caused by viral infections.
• The severity of clinical manifestations is
  related to age of the patients.
• Infants present mild local symptoms and severe
  systemic symptoms, while older children present
  on the contrary.
• A stuffy, congested nose may exist in infants
  younger than 3 months of age.
• Treatment for the common cold should be mainly
  symptomatic. Antibiotics should not be used
  unless in those young, infant patients which are
  suspected to complicate bacterial infections.

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Acute Bronchitis

• Acute bronchitis is inflammation of the
  tracheobronchial epithelium .
• Trachea is usually involved,so acute bronchitis
  is also called acute tracheobronchitis.
• Acute bronchitis is commonly secondary to an
  acute viral infection, or just one manifestation
  of acute infectious disease.

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Etiology

• Infectious factorsviral, bacterial or other
  pathogen infections
• Characters of respiratory tract of infants The
  mucous become edema and hyperemia which make the
  bronchus narrower when inflammation.
• Other factorsimmunodeficiency, nutritional
  diseases, specific body constitution.

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Clinical Manifestation

• Begins as an URI
• Cough is a significant signs nonproductive
  cough? productive
• The systemic symptoms is usually serve in infants
  including fever, vomiting and diarrhea
• Medical examination
• Respiratory rudeness
• Diffuse or scattered rales
• No dyspnea
• CXR may be normal
• or thickening lung markings

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Summary

• Acute bronchitis is an inflammation of
  the major conducting airways within the lung
  which caused by viral or bacteria, and is most
  often in infants. Cough is the most significant
  clinical manifestation. Fever, vomiting and
  diarrhea are frequent in infants. Respiratory
  sounds are rough and scattered rales are heard on
  auscultation. Radiographic examination of the
  chest may show a mild increase in bronchovascular
  markings. Antibiotics are indicated if a
  bacterial infection of the airway is suspected or
  proven. Corticosteroids are recommended in severe
  cases.

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Acute Pneumonia

• Pneumonia is an inflammation of the parenchyma of
  the lungs.
• Most cases of pneumonia are caused by
  microorgnanisms, but there are several
  noninfectious causes, which include aspiration of
  food or gastric acid, foreign bodies and so on.

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Epidemiology

• Season of onset
• Age of onset
• Morbidity rate
• Mortality rate

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Category

• Classified according to the infecting organism
• Viral pneumonia, bacterial Pneumonia,
  mycoplasma Pneumonia.
• Classified according to Pathology
• Bronchopneumonia, lobar
  pneumonia,interstitial pneumonia.
• Classified according to duration of disease
• Acute pneumonia(lt1 mo), persistent
  pneumonia(1-3 mo) and chronic pneumonia(gt 3mo).
• Classified according to severity of disease
• Mild pneumonia and severe pneumonia.

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Etiology
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Inducement
Patients with the following problems are
particularly predisposed to this disease
Age
More often in infants
Disease
Malnutrition, Congenital heart disease,
Immunodeficiency disease
Environment
The recidence is wetness, stuffiness and
crowding.
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Pathology

• Hyperemia, edema and inflammatory infiltration of
  lung tissues
• Alveolar exudate
• Patchy Inflammation focus, and consolidation
• Atelectasis and emphysema of lung

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Clinical Manifestion
cough
Fever
four
pneumonia
symptoms
Rales
tachypnea
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Severe Pneumonia
Apart from the general features of
bronchopneumonia, severe pneumonia also present
with systemic toxic symptoms in respiratory
system, circulatory system, nervous system and
digestive system.
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Extrapulmoanry presentations
Intracranial hypertension Encephaledema
Nervous system
Myocarditis, heart failure Microcirculation
disturbance
Circulatory system
Gastrointestinal dysfunction, enteroplegia Aliment
ary tract hemorrhage
Digestive system
Mixed acidosis, dehydration Hyponatremia
Water-Electrolyte Balance
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Myocardial failure

• Suddenly onset of tachypnea, Rgt60 bpm, increased
  pulmonary rales.
• Tachycardia that can not be explained by high
  fever or tachypnea, HRgt180 bpm
• Irritability and cyanosis
• Gallop rhythm or dull heart sound , distension
  of jugular vein and enlarged cardiac
• Increased liver with tenderness, gt 1.5cm.
•  Oliguria or anuria that present with edema of
  eyelid or lower extremities.

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Complication

• Empyema of pleura
• Purulent pneumothorax
• Bullae of lung
• OthersSepticemia
• Purulent pericarditis

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Laboratory Examination

• Peripheral blood examination
• White cell count
• CRP (C-reactive
  protein)
• Nitroblue
  tetrazolium test
• Etiological examination
• Bacteriological examination
• Bacterial culture
• Virological examination
• Viral isolation
• Examination of mycoplasma
• Specific immunity
  examination

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Lobular pneumonia (Bronchopneumonia)

• Pathogen
• Streptococcus pneumoniae
• Haemophilus influenzae
• Pathology
• Pathological changes such as hyperemia and
  edema of bronchiolar wall, exudation of pulmonary
  lobule, and bronchiolar obstruction are scattered
  surround bronchus.
• Clinical manifestation
• Hyperpyrexia, cough, tachypnea and dyspnea
• More common in infants, aged people and weak
  people

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Chest radiographic findings in bronchopneumonia

• Increase lung markings

• Diffuse bilateral Patchy infiltrates and
  consolidation scattered throughout both lungs

• Atelectasis, hyperinflation,
• bullae of lung and pyothorax

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Chest radiographic findings in bronchopneumonia
Frontal views Patchy infiltrates and
consolidation at the inner zone and middle zone
of bilateral lower lobes, with or without
hyperinflation
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Segmental atelectasis
Frontal views It is a segmental atelectasis at
the right superior lobe. The transversa fissure
is displaced toward the airless lobe. There is a
sector high density shadow with the apex toward
the hilum of lung. The diaphragm is elevated and
the mediastinum is shifted to the side of
involvement.
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Lobar pneumonia

• Pathogen maily streptococcus pneumoniae
• Pathology inflammtion infiltrates throughout a
  whole lobe or segment of the lung.
• Main clinical manifestation
• More common in adolescence, rare in young
  children.
• Hyperpyrexia, cough, and rusty sputum
• X-ray findings Change after changes of clinical
  symptoms.

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Lobar pneumonia at middle lobe of right lung
Frontal views A consolidation within the
transverse fissure and oblique fissure can be
seen at the middle lobe of right lung,
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Bronchiolitis

• viral disease, RSV (85).
• aged 2-6 months.
• airway obstruction is due to pathological changes
  include swelling and distension of bronchioles,
  secretions blockage.

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Clinical Manifestation

• expiratory wheezing
• tachypnea, nasal flaring
• Cyanosis
• fine rales
• emphysema
• The duration of illness is 4 7 days

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Chest radiographic findings

• Hyperexpansion is commonly present
• Peribronchial cuffing
• Increased interstitial markings
• Patchy infiltrates

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RSV Pneumonia
Frontal views of CXR Ground-glass opacity
Decreased lung markings Patchy infiltrates in
innner and middle zone Acquired hyperinflation
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Pneumonia of newborn

• Escherichia coli is the most common pathogen in
  neonate. In young infants gt 1 week, mainly
  pathogen are staphylococcus aureus and hemolytic
  streptococcus.
• Some patients may present only with signs of
  generalized toxicity. Patient uauslly present no
  cough or fever. Rales are seldom heard on
  ausculation. Clinical manifestation may be
  milk-resistant, drowsiness, low response, and
  tachypnea.
• Cyanosis, foaming at mouth, nodding respiration
  or apnea may present in severe cases.
• Respiratory signs is rare.

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Chest X-ray
Frontal views There is patchy shadows and
infiltrates at right lung field.
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Adenovirus pneumonia

• Type 3,7 adenovirus
• Young children(6 mo-2 yr )are more often affected
• Acute onset of high fever, toxic symptoms and
  pale face. Sometimes present with cardiac
  dysfunction and symptom of nervous system
• Severe cough, dyspnea and wheezing
• Respiratory signs such as fine rales occur after
  3-4 days
• Patchy infiltrates and consolidation with
  hyperinflation.

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Adenovirus pneumonia
Frontal views Chest radiographs reveals diffuse
interstitial and patchy alveolar infiltrates,
peribronchial thickening, and focal consolidation
throughout both lung field.
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Staphylococcal pneumonia

• More common in neonate and infants
• Present a sudden onset and progress quickly
• Signs include rashes, severe toxic symptoms,
  digestive symptoms, convulsion and shock
• Signs vary with stage of disease
• Consolidation of lung is obvious
• Chest X-ray reveals infiltrates, abscess and
  bullae of lung

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Abscess of lung
Frontal views Multiple round high density
shadow in both sides
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Pyopneumothorax
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Encapsulated pleural effusion
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Pulmonary Bulla
Female,7 day,hyperpyrexia and no crying CXR
multiple giant air-containing cavity
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Mycoplasma pneumonia

• Common cause of symptomatic pneumonia in older
  children
• Fever, dry cough are common symptoms
• Extrapulmonary complications sometimes occur
• Chest radiographs are untypical, usually
  demonstrate interstitial or bronchopneumonic
  infiltrates

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Interstitial infiltrates in Mycoplasma pneumonia
A 5-year-old boy complain of fever and cough. MP
antibody () Frontal views of CXR Increased lung
markings Diffuse patchy infiltrates Volume loss
of lower lobes of bilateral lung Enlarged hilar
shadow
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Diagnosis

• Peak age of onset
• Clinical manifestation
• Laboratory examination
• X-ray examination
• Others

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Differential Diagnosis

• Acute bronchitis
• Pulmonary tuberculosis
• Foreign body in bronchus

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Treatment

• Nursing and supporting therapy
• Symptomatic treatment
• Oxygen supply Conscious sedation
• Pyretolysis Cough suppressants
• Eliminate sputum
• Antimicrobial therapy
• Treatment of complication
• Enhance immunity function
• physical treatment

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Antimicrobial treatment

• Principle of antibiotic treatment
• Sensitive
• Early treatment
• Sufficiency
• Drug combination

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Antibiotic treatment
Streptococcus pneumoniae penicilin Amoxicillin
Bacillus influenzae Amoxicillin plus clavulanate 2nd or 3rd-generation cephalosporins
Staphylococcus aureus Oxacillin sodium Vancocin
Moraxelle catarrhalis Amoxicillin plus clavulanate
Mycoplasma Pneumonia Erythromycin Macrolide
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Antiviral treatment

• There is no ideal drug in antiviral therapy.
• Ribovirin
• interferon (IFN)
• Human Immunoglobulin
• Traditional chinese drug therapy
• Yuxingcao, Double coptis

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Indication of Systemic corticosteroids

• Severe toxic symptom that include shock,
• ultrahyperpyrexia and toxic encephacopathy
• Increased secretions and bronchial spasm
• Complicated with pleural effusion in early
  period

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Treatment of severe pneumonia

• Heart failure
• cardiotonic, sedative
• diuresis and oxygen supply
• Respiratory Failure
• suctioning, oxygen supply
• intubation and artificial respirator
• Toxic encephacopathy
• anti-infection, oxygen supplY,
• correct acidosis

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Summary

• Fever, cough, tachypnea and fine rales are four
  major symptoms of pneumonia.
• Besides, severe pneumonia present circulatory,
  neurological and digestive symptoms
• Diagnosis mainly depends on clinical
  manifestations and X-ray examination.
• According to the characteristics of clinical
  symptoms, signs and auxiliary examination, we
  classify different type and severity.   
• Treatment should emphasize comprehensive
  treatment.
• Choose different antibiotics according to
  different pathogens.
• Pay attention to the importance of nursing,
  supporting therapy, and symptomatic therapy.

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