Respiratory

system
•Foreign bodies include items such as peanuts,
beans, coins, buttons, nuts, uninflated balloon,
etc.
•If the foreign body (FB) enters the airway, it may
lodge at the level of the larynx, trachea, or
bronchioles
•When FB is lodged in the airway, respiratory
distress may occur

•Children less than 4 years of age are at risk for

FB aspiration because of the size of their trachea
and a tendency to put things in their mouths
Presentation
•Symptoms may be minor if the object is small or
may include choking
•Factor involved include size of the FB and
location
•Larynx is the most common site for a FB if the
child <1 year
•Trachea & bronchi the most common sites for FB
aspirations in children >1 year, especially the
right main stem bronchus
•Stridor if FB lodges in the pharynx
•History may be highly suggestive of FB
aspiration even if the aspiration was not
witnessed
Physical examination
•Wheezing, stridor,, or bloody sputum
•Unilateral absence of breath sounds
•Fever if FB present in the airway for a period of
time
•A nonobstructing and nonirritating FB may cause
minimal symptoms even after an extended period
of time

Diagnostic tests
•CXR (inspiratory and expiratory): shows ball-
valve mechanism; lung with the FB to remain
overaerated in expiration
Treatment
•Removal of the FB with a rigid open-tube
bronchoscope
•If a secondary infection present, antibiotics

Complications
•Aspiration pneumonia
FB lodged in the airway must be removed
Complete recovery expected if the patient with
FB diagnosed and treated quickly
Prevention
•FB aspiration can be prevented
•Anticipatory guidance should be given to parents
to keep small objects out of the reach of young
children
•Hot dogs, peanuts, grapes, popcorn, and peanut
butter should NOT be given to young children

D/D
•Asthma
•Pneumonia, if fever is present
•The most common syndrome of infectious upper
airway obstruction

•Parainfluenza virus the predominant cause

•Adenovirus, respiratory syncytial, influenza and
measles viruses
•Other family members may have mild
respiratory illness, ie, cold symptoms

Presentation
•Child is usually between 3 months and 5 years
•Slightly elevated temp and a mild respiratory
illness
•Cold symptoms may be present for several days
Physical examination
•Low-grade fever, barking cough and intermittent
inspiratory stridor
•As upper airway obstruction increases, the
patient exhibits stridor at rest, nasal flaring and
suprasternal, infrasternal, and intercostal
retractions
•Those with more severe obstruction are at risk
for hypoxia, hypercapnia, tachycardia, and
eventual death from hypoventilation

Diagnostic tests
•X-ray of the nasopharynx and upper airway
Treatment
•Mild croup can be managed at home
•Keep the child calm and watch for respiratory
distress
•Steam from a vaporizer or steam from a shower
in a closed bathroom may terminate acute
laryngeal spasm
•“Cold steam” from a nebulizer
•Continuous humidification(either hot or cold) for
a few days

•If stridor at rest, epinephrine and corticosteroid

(dexamethasone IM)
•Patient observed for 2-4 hours for rebound
Complications
•Middle ear and lung infections from the virus
•Bacterial tracheitis

D/D
•Spasmodic croup
•Bacterial tracheitis
•Diphtheritic croup
•Epiglottitis
•An acute inflammation of the epiglottis causing
respiratory distress from airway obstruction

•H. Influenzae type B the most common pathogen

•More frequently seen in children ages 2 – 7 years
old

•Family members do not have upper respiratory

infections

Presentation
•Sudden onset of high fever, dysphagia, drooling,
muffled voice, and respiratory distress
Physical examination
•Stridor, nasal flaring, and retractions
•Air hunger that progresses to cyanosis, coma,
and death

Diagnostic tests
•Clinical features
•Enlarged inflamed epiglottis by direct
examination or laryngoscopy by physicians who
are expert in endotracheal intubation and
tracheostomy
•Airway usually obtained in operating room
•Lateral X-ray of the neck shows “thumb print”
Treatment
•Airway should be secured regardless of the
degree of respiratory distress
•Anesthesiologist or otolaryngologist should
perform intubation
•Intubation usually performed under GA in the OT
•When intubation cannot be performed, a
tracheostomy should be done
•After intubation a blood culture should be drawn
and IV fluids and antibiotics started
•Before culture results, 3rd generation
cephalosporin (cefotaxime, ceftriaxone) or
ampicillin with sulbactam parenterally
Complications
•A tongue blade should never be used to examine
the pharynx in a patient with suspected
epiglottitis because of reflex laryngospasm and
cardiorespiratory arrest during or immediately
after the examination
•Unless treatment is obtained, death may ensue
from complete obstruction of the airway
•Meningitis, pneumonia, or otitis media may occur

D/D
•Croup
•FB aspiration
•Peritonsillar abscesses, retropharyngeal
•A reversible obstructive airway disease that
affects both small and large airways
•Three components of an asthma attack
Bronchospasm
Mucus production
Airway edema
•Obstruction caused during the asthma attack
causes increased airway resistance and
decreased forced expiratory volumes and flow
rates
•Lungs hyperinflated
•There is premature airway closure, increased
work of breathing, and changes in the elastic
•Etiology believed to be genetic, environmental,
or a combination
•Immunologic, endocrine, infectious, autonomic,
and psychologic may contribute

Presentation: Acute or insidious

Physical examination
•Wheezing, dyspnea, a prolonged expiratory
phase of respiration, accessory muscle use and
retractions
•Patient may have abdominal pain from use of the
abdominal muscles
•Liver and spleen may be palpable secondary to
Diagnostic tests
•Family history of asthma or atopy
•History of recurrent cough and wheezing,
especially with exposure to “triggers” (exercise,
viral infection, weather changes, allergens, and
emotions)
•Eosinophilia
•Allergy skin testing
•Pulmonary function tests
•X-ray of chest not always required for every
patient
•Arterial blood gases indicated when 1) Clinical
deterioration 2) inability to maintain O2 saturation
above 95% and 3) suspicion of a pneumothorax
Drugs used in bronchial asthma

•Bronchodilators
Sympathomimetics: Salbutamol, Terbutaline,
Salmeterol
Methylxanithines: Theophylline, Aminophylline
Anticholinergics: Ipratropium bromide

•Leukotriene antagonists: Montelukast, Zafirlukast

•Mast cell stabilizers: Sodium cromoglycate,

Nedocromil, Ketotifen

•Corticosteroids
Systemic: Hydrocortisone, Prednisolone
Treatment
•Avoidance of triggers

Short-acting β 2 agonists
•Most effective drugs for acute bronchospasm
•Careful instruction for proper use critical
•May need spacer/Aerochamber
•Regularly scheduled daily use not recommended
•Prophylactic use- exercise

Long-acting inhaled B-agonists (LABA)

•Routine daily controller and not for acute relief
•Dose in every 12 hours (not BID)
•Salmeterol + fluticasone
Mild intermittent asthma
•Symptoms occur less than or equal to twice a
week
•Nocturnal symptoms less than or equal to twice
a month
•PRN use of inhaled, short-acting β 2 agonists
•Treat flares with inhaled or systemic steroids if
necessary

Mild persistent
•Symptoms occur more than twice a week
•Nocturnal symptoms occur more than twice a
month
•Long-term control with daily anti-inflammatroy
Moderate persistent
•Daily symptoms plus exacerbation ≥ twice a
week
•Low-dose inhaled corticosteroids (ICS) and long-
acting B agonist (LABA), or
•Medium-dose ICS
•Alternative therapy: low-dose ICS with
leukotriene-receptor antagonist
Severe persistent
•Continual symptoms with frequent exacerbations
•High-dose ICS and LABA
•Consider leukotriene antagonist
•If needed, may add systemic steroids
•Make repeated efforts to reduce systemic
•Exercise-induced asthma best prevented by
inhalation of β 2 -agonist immediately before
exercise

Quick-relief medications: Acute rescue

•Short acting beta2-agonists (minutes)
•Anticholinergic agents
•Systemic corticosteroids (hours)

Long-term control medications: Maintenance

•Inhaled corticosteroids
•Long-acing β 2 -agnosits
•Leukotriene modifiers
•Mast-cell stabilizers
Complications: Pneumothorax

D/D
Other causes of wheezing:
•Postinfectious
•Infectious
•CHD
•Foreign body
•Chronic aspiration
•Extrinsic airway compression
•Immunodeficiency
•Congenital airway anomaly
•Cystic fibrosis
•Ciliary dyskinesia
•A lower respiratory infection in infants caused by
inflammatory obstruction of the small airways of
the lower respiratory tract

•Occurs in children younger than 2 years of age

with a peak incidence at approximately 6 months
of age
•A virus, usually respiratory syncytial virus (RSV),
invades the bronchioles causing obstruction from
mucus, cellular debris, and edema
•Parainfluenza type 3 viruses, mycoplasma, and
adenovirus
•Infants with mothers who smoke cigarettes are
Presentation
•H/O URTI, rhinorrhea, and sneezing
•Fever of 38.5- 39oC
•Tachypnea, wheezing, and cough
•Difficulty in feeding
•Mild cases resolve in 1 – 3 days
•In severe cases, the course is lengthened

Physical examination
•Tachypnea (usually 60 -80 breaths/ min)
•Wheezing, rales, intrcostal and subcostal
retraction
•In severe cases the patient may be restless and
Diagnostic tests

•CXR:
hyperinflation of the lungs
Air trapping and peribronchial thickening
Atelectasis

•CBC and differential within normal limits

•Virus in nasopharyngeal secretions detected with

Ag detection, PCR or culture
Treatment
In uncomplicated cases: symptomatic
•Fluids, antipyretics and humidified air or O2
•A trial of a bronchodilator
•Aerosolized epinephrine
•Corticosteroids not indicated
•Antibiotics only if secondary bacterial infection

Criteria for hospitalization of the child

•High-risk infants: premature, infants younger
than 3 months, immunodeficiency, and chronic
lung and congenital heart diseases
•Respiratory rate greater than 60 breaths/ min
•PO2 less than 60 mm Hg on room air
•Apnea; feeding difficulties
•Ribavirin, an aerosolized antiviral agent for
infants with impending respiratory failure,
immunodeficiency, bronchopulmonary dysplasia,
neuromuscular weakness, or congenital heart
disease

•Some may need mechanical ventilation if

respiratory failure

Complications
•Apneic spells in infants
•Mortality less than 1%
•Dehydration secondary to inability to feed
•Uncompensated respiratory acidosis
At-risk infants for bronchiolitis (infants younger
than 2 years with chronic lung disease or
prematurity)
•RSV immune globulin intravenous (RSV-IGIV) or
monoclonal antibody (palivizumab) to RSV
before and during RSV season to prevent severe
RSV

D/D
•Asthma
•FB airway
•Heart failure
•Cessation of breathing for greater than 20 s
•Obstructive sleep apnea (OSA) is a combination
of prolonged partial upper airway obstruction and
intermittent cessation of breathing resulting in
disruption of sleep and breathing patterns

•Adenotonsillar hypertrophy, trisomy 21, cleft

palate, macroglosia, nasal obstruction, and
neuromuscular disease are risk factors for OSA
Presentation
•Snoring
•Child may have restless sleep, stop breathing,
and wake up frequently

Physical examination
•Mouth breathe
•Large tonsils and a hyponasal voice
•Associated craniofacial sydrome, trisomy 21, or
neuromuscular disease

Diagnostic tests
•C/F
•Polysomnography (a sleep study test)
Treatment
•Adenotonsillectomy

Complications
•Poor growth, cor pulmonale, poor school
performance, and death

D/D
Three types of apnea:
•Central: lack of respiratory effort
•Obstructive: total airway obstrution
•Mixed
Mixed apnea

Apnea of prematurity:
•Occurs in premature infants less than 36 weeks
of gestational age
•Apnea and bradycardia seen
•Treatment: theophylline or caffeine, or intubation

Cyanotic breath-holding, ie,breath-holding

spells
•Caused by prolonged expiratory apnea and
cerebral anoxia
•Younger than 3 years of age and hold their
breath because of anger, etc
Pallid breath-holding:
•Usually occurs after a painful stimulus
•Patient turns pale, ie, “white”, and have asystole
and a seizure
•Treament: atropine

Obesity hypoventilation (morbid obesity,

Prader-Willi syndrome)
•Usually caused by airway obstruction
•May also involve central control
•Obesity, somnolence, polycythemia, and cor
pulmonale
•An unexplained death by history or by thorough
postmortem examination of an infant less
than 1 year old
•Postmortem exam includes autopsy,
investigation of the scene of death, and medical
history review
•Most common cause of death in infants 1 – 12
months of age

Risk factors/ etiology

•No clear etiology for SIDS (respiratory pattern,
chemoreceptor sensitivity, arousal responses,
temp regulation, and cardiac control)
•Most deaths occur between midnight and 9 AM
and more cases occur in the winter
Other risk factors:
•Prematurity, lack of prenatal care, maternal
smoking during pregnancy, and lower
socioeconomic conditions
•Prone and side sleep positions

•Infants with apparent life-threatening events

(ALTE) have a 3- 5 times increased risk of SIDS
•Siblings of SIDS victims have a 4-5 times
increased risk of being a SIDS victims themselves
Presentation/ Physical examination
•In all cases the child is les than1 year of age
•Death unexplainable either by history or by
thorough postmortem examination

Diagnostic studies
•No diagnostic studies that determine which
children are at risk for SIDS

•On autopsy, mild pulmonary edema and diffuse

intrathoracic petechiae
•Tissue markers of chronic asphyxia
Treatment/ Prevention

•Sleep position, placing the infant on his or her

back during sleep (unless medically
contraindicated)
•Patients who have experienced ALTE may need
home electronic monitoring of heart rate,
respiratory pattern, and oxygenation
An inflammation of pulmonary tissue, associated with
consolidation of the alveolar spaces
Classified by location as:
Pneumonitis: lung inflammation with or without
consolidation
Interstitial pneumonitis consists of inflammation of the
interstitium,ie, walls of the alveoli, alveolar sacs and
ducts or bronchioles
Lobar pneumonia: inflammation localized to one or more
lobes of the lung with complete consolidation
Bronchopneumonia: inflammation centered in the
bronchioles with mucopurulent exudate
Risk factors/ etiology
Infectious agents such as viruses, bacteria, fungi, and
parasites
Inhaled toxins may cause aspiration pneumonia
Viral pneumonia the most common pneumonia in
childhood

Presentation/ Physical examination

Clinical triad: Fever, tachypnea and cough
Viral pneumonia: cough, wheezing, and stridor
Bacterial pneumonia:
cough, high fever and SOB; decreased breath sounds
and dullness to percussion over the consolidation
Mycoplasma pneumonia or “walking” pneumonia:
Patients less ill than their CXR demonstrates;
non-productive cough

Chlamydia pneumonia:
Patients usually 6 weeks to 6 months of age;
“staccato cough;
H/O eye discharge during day 5-14 of life; low-grade or
no fever;
mother may give the H/O vaginal infection during
pregnancy;

Aspiration pneumonia: H/O inhaling a toxin or

aspirating food; wheeze, cyanosis
Diagnostic tests

CXR:
Viral pneumonia: diffuse streaky infiltrates
Bacterial pneumonia: lobar consolidation
Mycoplasma pneumonia: interstitial pattern most
commonly in the lower lobes
Chlamydia pneumonia: hyperinflation or a ground
glass appearance
Aspiration pneumonia: alveolar and rarely reticular
infiltrates that are usually localized but often bilateral
Chest X-Ray showing pneumonia
CBC:
Viral pneumonia: normal WBC with a predominance of
lymphocytes
Bacterial pneumonia: Increased WBC with neutrophilia
Chlamydia pneumonia: normal WBC, but eosinophilia
may be present

Isolation of an organism from blood or pleural fluid

Sputum culture
Nasopharyngeal swabs to detect viral agents
Serum cold hemagglutinins in a 1:64 titer or a positive
IgM Mycoplasma pneumoniae support the diagnosis of
M. pneumoniae
Treatment
When appropriate, antibiotics should be given
The choice of antibiotics depends on the organism
suspected and the age of the child
Chlamydia pneumonia: usually seen in patients 6
weeks to 6 months old,
Erythromycin ethyl succinate drops (EES) by mouth for
14 days;
Mothers and their sexual partners also need to be
treated
Group B Streptococcus, Escherichia coli, Listeria:
Usually seen in patients from birth to 2 months,
Ampicillin plus an aminoglycoside or ampicillin plus a
third generation cephalosporin via IV
S. pneumoniae, H.influenzae, and Staphylococcus:
Usually seen in patients 2 months old to 5 years old
For in-patient therapy, a cephalosporin such as
cefuroxime or ceftriaxone IV
For outatient therapy: amoxicillin, amocxicillin-
clavulinate, or erythromycin plus sulfosoxazole
M. pneumoniae: Usually seen in patients older than 5
years old along with S. pneumoniae
Erythromycin, azithromycin, or clarithromycin

Complications:
Empyema may be a complication of pneumococcal and
staphylococci pneumonia
Seen more commonly in infants than in older children
Pneumonia in young infants
Pneumonia in older infants and children