Pediatric Respiratory
and require other techniques
History
o Includes onset, duration, and frequency of respiratory symptoms, and exposure to others with
respiratory illness
o Obtain information concerning the severity and pattern
o For infants, a feeding history should be obtained
o Family history should include questions about asthma and atopy, immune deficiencies, and CF
o Environmental history queries exposure to smoke, pets, and pollutants
Physical Exam
o Any factor that impairs respiratory mechanics is likely to increase the respiratory rate
o It is important to observe the respiratory pattern and degree of effort (work of breathing)
o Hyperpnea (increased depth of respiration) may be observed with fever
o Increased work of breathing can be described as inspiratory (intercostal, supraclavicular, or
substernal retractions) or expiratory
o Increased inspiratory effort is also manifested by nasal flaring
o Grunting suggests respiratory distress, but it may also be a manifestation
o Stridor is a harsh sound caused by a partially obstructed extrathoracic airway, more commonly
heard on inspiration
o Wheezing is produced by partial obstruction of the lower airways, more commonly heard during
exhalation can be monophonic and low-pitched or high-pitched and musical
o Crackles or rales fluid or secretions in small airways may produce sounds characteristic of
crumpling cellophane
o Digital clubbing seen in CF and in other, less common chronic pulmonary diseases
Generally not seen in asthma, so its presence should heighten concern for other diagnoses
o Cough results from stimulation of irritant receptors in the airway mucosa
o Chronic cough is defined as a daily cough lasting longer than 3 weeks
Diagnostic Measures
o Imaging techniques
Chest radiographs determine lung abnormalities, they provide information about the bony
thorax, the heart and the great vessels. Should be obtained in both the PA and lateral
projections and, if possible, following a full inspiration
Barium esophagram may be valuable in diagnosing disorders of swallowing (dysphagia) and
esophageal motility, vascular rings (esophageal compression), tracheoesophageal fistulas,
and, to a lesser extent, gastroesophageal fistula
o Computed tomography (CT) scan of the chest
Image of choice for evaluating pleural masses, bronchiectasis, and mediastinal lesions as
well as delineating pleural from parenchymal lesions
Magnetic resonance imaging (MRI), useful in visualizing cardiac and great vessel anatomy,
less useful for evaluation of pulmonary parenchymal lesions
o Ultrasonography
Can be used to delineate some intrathoracic masses and is imaging procedure of choice for
assessing parapneumonic effusion/empyema
Useful for assessing diaphragmatic motion in small children
Measures of Respiratory Gas Exchange
o Properly performed arterial blood gas analysis provides information about the effectiveness of
both oxygenation and ventilation
o Pulse oximetry measures the O2 saturation of hemoglobin by measuring the blood absorption of
two or more wavelengths of light; noninvasive, easy to use, and reliable
o Transcutaneous electrodes can be used to monitor PCO2 and PO2 at the skin surface, but are
less accurate
Pulmonary Function Testing
o Measured with spirometry
o During the forced expiratory maneuver, forced vital capacity (FVC), forced expired volume in
the first second (FEV1), and forced expiratory flow (FEF) rates are measured
o Body plethysmography airway resistance, FRC, and RV cannot be measured with spirometery
o Obstructive airway disease low flow rates and increased RV or FRC
o Restrictive defect low FVC and TLC, with relative preservation of flow rates and FRC
o Mean midexpiratory flow rate (FEF25-75%)
o Peak expiratory flow rate (PEFR) can be obtained with a simple handheld device and may be
useful for home monitoring of older children with asthma
o Inhalation challenge tests using methacholine, histamine, or cold, dry air are used to assess
airway hyperreactivity
Endoscopic Evaluation of the Airways
o Endoscoic evaluation of the upper airways (nasopharyngoscopy) is performed with a flexible
fiberoptic nasopharyngoscope to assess adenoid size, patency of the nasal passages, and
abnormalities of the glottis
o Bronchoscopy is useful in identifying airway abnormalities and in obtaining airway samples for
culture, especially in immunocompromixed patient s
o Transbronchial biopsies are rarely performed in children
Examination of Sputum
o Difficult to obtain in young children
Lung biopsy
o Thoracoscopic procedure or a thoracotomy is preferred if thorough histologic evaluation is
desired
Therapeutic measures
o Oxygen administration any child in respiratory distress should be treated with supplemental
O2 to maintain normal O2 sat levels
Long term administration use a nasal cannula
Humidified high flow nasal cannula allows the provider to more comfortably deliver higher
flow rates while controlling FIO2 and is widely used in neonates
o Aerosol therapy accomplished via inhalation of dry powder inhaler (DPI), metered dose
inhaler (MDI), or nebulizer
o Chest physiotherapy and clearance techniques: chest percussion (moves secretions toward
central airways)
o Intubation: artificial airway; endotracheal tubes can damage larynx and airways if not properly
sized
o Laryngeal mask airway (LMA)
o Mechanical ventilation positive pressure ventilation requires an artificial airway
Noninvasive ventilation is useful in patients with obstructive sleep apnea and neuromuscular
disease
Ventilation controlled by central chemoreceptors
o Modulated by peripheral receptors in the carotid and aortic bodies
o Full lung inflation temporarily inhibits inspiratory effort in infants (Hering-Breuer reflex)
Acute Life-Threatening Events
o Any unexpected and frightening change in condition characterized by apnea, color change (blue
or pale), sudden limpness, choking, or gagging
o Gastroesophageal reflux and laryngospasm are the most common causes of ALTE and are a/w
emesis, choking, or gagging
o CNS causes: intracranial bleeding
o Acute infection with respiratory viruses, pertussis, and serious bacterial infections can also cause
apnea in infants
o Diagnostic Studies
History premature birth, prior apnea, level of consciousness at the time of event, presence
or absence of respiratory effort, limpness or stiffness, jerking movements, feeding history,
intercurrent illnesses, any trauma, social situation of family
PE bruising and injury, general and neurologic condition of infant, nutritional status,
respiratory pattern, cardiac status
 Labs serum electrolytes, serum glucose, BUN, creatinine, hemoglobin, hematocrit, WBC, CT delineate the site of obstruction but may require sedation
CXR, and ABG Flexible nasopharyngoscopy/laryngoscopy good choice
Evidence of respirator infection test for respiratory viruses and pertussis o Adenoidal and Tonsillar Hypertrophy
Gastroesophogeal reflux barium swallow or pH probe Most common cause of UAO
Cardiorespiratory monitoring for 12-24 hours Signs: mouth breathing, snoring, and OSA
Sudden Infant Death Syndrome Diagnostics: lateral xray of nasopharynx or by flexible nasopharyngoscopy
o Unexpected death of an infant younger than 1 with and unexplained cause Tx: Most effective removal
o Higher risk in premature and low birth weight infants, infants of young impoverished mothers o Choanal Stenosis (Atresia)
who smoke, African American and Native American infants, and infants whose moms abused Congenital
drugs Obstruction of nasal passages
o Rare before 4 weeks or after 6 months Inability to easily pass a small catheter through the nostrils
o Associated with prone position during sleep, esp. on soft bedding Dx confirmed by CT scan and inspecting the area with a flexible nasopharyngoscope
o Some SIDS deaths may be due to prolongation of the Q-T interval, abnormal CNS control of Tx: surgery
respiration, and CO2 rebreathing from sleeping face down o Croup (laryngotracheobronchitis)
Apnea Most common infection of the middle respiratory tract
o Cessation of airflow due to either lack of respiratory effort (central apnea) or upper airway Most common causes: parainfluenza viruses (1, 2, 3, 4) and RSV
obstruction (obstructive apnea) Most common in children 6 months 3 years; peak in fall and early winter
o Central apnea <10 seconds is common in healthy babies Typically follows a common cold
o Pauses lasting longer than 15-20 sec is abnormal Adolescents laryngitis
o Premature infants can have apnea of prematurity recurrent apneic episodes that are often of Symptoms:
central origin; should resolve by 44 weeks postconceptional age Barking or brassy cough, hoarseness, inspiratory stridor, low-grade fever, respiratory
o Congenital central hypoventilation rare genetic disorder in which there is a profound loss of
distress
respiratory control during sleep leading to central apnea, hypercarbia, and hypoxemia Labs and Imaging:
Defect in the PHOX2B gene
AP radiograph of neck shows subglottic narrowing of croup (steeple sign)
A/w an increased risk of Hirschsprung disease and neural crest tumors
Spasmodic croup sudden onset of symptoms, usually at night, but w/o a significant upper
o Obstructive sleep apnea syndrome (OSA) complete or partial upper airway obstruction during
respiratory tract prodrome
sleep
Tx:
Adenotonsillar hypertrophy is the most common cause of OSA in young children
Oral or intramuscular dexamethasone
Diagnosis should be confirmed with a polysomnoram
o Epiglottitis
Continuous recording of EEG and eletro-oculogram for sleep staging, oronasal airflow
Medical emergency
and pressure, audible snore, chest and abdominal wall excursion, leg and chin
Caused by group A strep or Staph aureus or Haemophilus influenza type b in unimmunized
electromyogram, electrocardiogram, pulse ox, and capnography
Measured score = apnea-hypopnea index or number of times in an hour of sleep that pts
Pts will be sitting, often with head held forward, mouth open, jaw thrust forward (sniffing
the child has cessation or reduction of airflow of a significant magnitude
Treatment: CPAP or BiPAP position)
Lateral xray = bulging epiglottis (thumb sign) and swelling of the aryepiglottic folds
Dx confirmed by observation of the inflamed and swollen supraglottic structures and
Upper Airway Obstruction (UAO)
swollen, cherry-red epiglottitis
o Blockage of any part of the airway located above the thoracic inlet
Requires and antibiotic therapy and ET intubation to maintain airway
o Supraglottic, glottis, and subglottic causes
o Bacterial Tracheitis
o More pronounced during inspiration
Superinfecion of trachea that may follow viral croup
o A/w stridor
Most commonly caused by S. aureus
Laryngomalacia (floppy larynx) is the most common cause of inspiratory stridor in infants
Spasmodic croup
and may be aggravated by swallowing
o Laryngomalacia
o Hoarsness suggests vocal cord involvement
Exaggerated collapse of the glottis structures, especially the epiglottis and arytenoid
o Children with UAO may have increased inspiratory work of breathing manifested by
suprasternal retractions cartilages, during inspiration
o Diagnostic May be due to decreased muscular tone of the larynx and surrounding structures or to
Radiography immature cartilaginous structures
Inspiratory stridor
Lateral views of neck and nasopharynx
Most common cause of stridor in infants
o Adenoidal hypertrophy and airway swelling
o Subglottic stenosis
AP view of neck with head in extension
Narrowing of the portion of the trachea immediately below the vocal cords
o Subglottic space should be symmetrical and the lateral walls of the airway should
May be congenital but more often is acquired
fall away steeply
ET intubation is required in some premature infants
o Asymmetry = subglottic stenosis or a mass lesion
Stridor that is frequently biphasic (inspiration and expiration)
 o Mass Lesions o Foreign Body Aspiration
Most common laryngeal tumor in childhood = hemangioma (usually presents before 6 Relatively uncommon
months) Most kids that do this are under 4 years of age
Subglottic lesions produce asymmetrical narrowing of the subglottic space on AP Foreign bodies tend to lodge in the right-sided airways
radiographs Most common foreign bodies aspirated are food and small toys
Definitive diagnosis = endoscopy Coins more often lodge in the esophagus than in the airways
Laryngeal webs = failed recanalization of the glottis airway in utero o Bronchiolitis
Laryngeal cysts = consequence of airway trauma Disease of small bronchioles with increased mucus production and occasional
Both can produce biphasic stridor bronchospasm, sometimes leading to airway obstruction
Foreign body should be considered in any infant or child capable of ingesting foreign Most commonly caused by a viral lower respiratory tract infection (RSV)
objects Presents as a progressive respiratory illness similar to the common cold
Juvenile laryngeal papillomatosis Prevention injections of palivizumab (RSV specific monoclonal antibody)
Rare condition of benign tumors caused by HPV-6 and HPV-11 acquired at birth from o Bronchopulmonary Dysplasia
maternal genital warts Oxygen dependence at 36 weeks postconceptual age accompanied by characteristic clinical
Manifestions start in infancy and include biphasic stridor and hoarse voice/cry and radiographic findings
Lesions are most commonly located in the larynx, but they can spread to the trachea Radiographic lung opacification and subsequently by development of cysts accompanied
o Vocal Cord Paralysis by areas of overdistension and atelectasis
More often caused by damage to the recurrent laryngeal nerve (left more susceptible) Clinical O2 dependence, hypercapnia with a compensatory metabolic alkalosis, pulmonary
Trauma and mediastinal lesions HTN, poor growth, and development of RHF
Central causes: Arnold-Chiari malformation, hydrocephalus, and intracranial hemorrhage o Endobronchial Mass Lesions
Biphasic stridor and alterations in voice and cry (weak cry, hoarseness, aphonia) Most common granulation tissue, results from local inflammation (TB)
Children at risk for aspiration Most common airway malignancy (rare) is the nonsecreting carcinoid tumor
o Congenital Lung Anomalies
Lower Airway, Parenchymal, and Pulmonary Vascular Diseases Congenital lobar over distension over inflation of one lobe of a lung; may be mistaken for
o Most common in children = asthma results in diffuse bronchial obstruction from airway a pneumothorax
inflammation, constriction of bronchial smooth muscle, and excessive secretions Pulmonary hypoplasia may cause congenital diaphragmatic hernia
o Wheezing in the first weeks or months of life is probably not asthma o Emphysema
o Wheezing localized to one area of the chest suggests focal airway narrowing Disruption or destruction of alveolar septa
o Obstruction below the thoracic inlet causes more wheezing on expiration than on inspiration Rare in children seen with alpha-1 antitrypsin deficiency
o Radiographic eval is not needed with each episode of wheezing Kartagener syndrome situs inverus, pansinusitis, bronchiectasis
o Generalized hyperinflation, indicated by flattening of the diaphragms and an increased AP o Pneumonia
diameter suggests diffuse obstruction of the small airways Infection of the lower respiratory tract
o Dysphagia leading to aspiration is best assessed with a videofluoroscopic swallowing study RSV infants
o Asthma Other resp. viruses (flu, adeno, etc.) kids <5
Airway hyperresponsiveness Mycoplasma >5
Chronic inflammation can lead to airway remodeling Strep pneumo is the most common cause of lobar pneumonia in anyone other than infants
Spirometry help establish the diagnosis Mycoplasma and Chlamydia cause atypical pneumonia (afebrile pneumonia)
Allergy skin test should be included o Pulmonary Edema
CXR should be preformed on the first episodes of asthma Dypspnea
LOOK AT THE ASTHMA LECTURE Kerley B lines
o Tracheomalacis o ARDS
Floppy trachea due to lack of structural integrity of the tracheal wall Respiratory failure
May be congenital or acquired Severe hypoxemia (200 mmHg of PaO2/FiO2)
Tracheal collapse may only be apparent during force exhalation or with cough o Pulmonary Arterial HTN (PAH)
Commonly aggravated by respiratory infections 5 groups:
o Tracheoesophageal Fistula 1: PAH due to diseases within veins and small pulmonary muscular arteries and
Most common forms occur with esophageal atresia idiopathic pulmonary arterial htn
A/w vertebral anomalies, anal atresia, cardiac anomalies, TEF, renal anomalies, and limb 2: dysfunction of the left heart
anomalies 3: secondary to lung disease or chronic hypoxia
Barium should not be used 4: chronic pulmonary thromboembolism
Tx: surgery 5: unclear multifactorial diseases
o Extrinsic Tracheal Compression Results in cor pulmonale
Compression by vascular structures or masses RHF leads to hepatic congestion, fluid retention, and tricuspid insufficiency
Most common cause is anterior compression from an anomalous innominate artery o Pulmonary Hemorrhage
 Idiopathic pulmonary hemosiderosis rare disorder characterized by recurrent alveolar Antibiotic therapy to control chronic infection (Pseudomonas!!!)
bleeding, iron deficiency anemia, and hemosiderin laden macrophages
Pulmonary hemorrhage bleeding from an intrathoracic source Chest Wall and Pleura
Present with hemoptysis o Thoracic scoliosis curve greater than 60 degrees; can lead to decreased lung volumes
Symptomatic airway hemorrhage may result in significant hemoptysis with few o Pectus excvatum
radiographic changes Sternal concavity
Alveolar bleeding often causes profound respiratory symptoms, hypoxemia, diffuse May result in restrictive lung disease
infiltrates on radiographs, and minimal hemoptysis o Pectus Carinatum
o Pulmonary Emoblism Sternum bows out
A/w indwelling central venous catheters, oral contraceptives, or hypercoaguable stats Not associated with abnormal pulmonary function
Hypoxia common and nonspecific ST-segment and T-wave changes o Pneumothorax
Diagnostic test of choice = CT angiogram of the chest Spontaneous primary pneumothorax teenagers and young adults (tall, thin males and
Gold standard = pulmonary angiography smokers)
Secondary pneumothorax barotrauma from mechanical ventilation, asthma, cystic fibrosis,
Cystic Fibrosis trauma to the chest, and severe necrotizing pneumonia
o Cystic fibrosis transmembrane regulator (CFTR) genre on chromosome 7 Clinical shoulder pain and dyspnea
Chloride channel on apical surface of epithelial cells Tension pneumothorax severe respiratory distress and cyanosis; life threatening
Most common mutation is a deletion of 3 base pairs resulting in the absence of o Pneumomediastinum
phenylalanine at the deltaF508 position Dissection of air from the pulmonary parenchyma into the mediastinum
o Clinical digital clubbing, nasal polyposis, protein and fat malabsorption Symptoms chest pain and dyspnea
o Allergic bronchopulmonary aspergillosis is a hypersentivity rxn to Aspergillus o Pleural Effusion
o 90% of pts born with exocrine pancreatic insufficiency Fluid accumulates in the pleural space when local hydrostatic forces that are pushing fluid
o Fat malabsrotion leads to steatorrhea out of the vascular space exceed the oncotic forces that are drawing fluid back into the
o 10% of pts are born with an intestinal obstruction caused by inspissated meconium (meconium vascular space
ileum) Can be transudates or exudates
o Older pts may have intestinal obstruction from thick inspissated mucus in the intestinal lumen Bacterial pneumonia can lead to an accumulation of pleural fluid (parapneumonic effusion)
(distal intestinal obstruction syndrome) When the fluid is purulent or infected = empyema
o May present with insulin deficiency (CF-related diabetes) Due to pneumonia caused by strep pneumo, group a strep, or staph aureus
o Dx: sweat test; elevated sweat chloride tests Tx:
o Tx: Drain fluid with a chest tube
Airway secretion clearance techniques (chest physiotherapy)
Surgery