APPROACH TO PEDIATRIC PULMONARY DISEASES Emily B. Gaerlan-Resurreccion, MD Pediatric Pulmonologist

APPROACH TO PEDIATRIC PULMONARY

DISEASES

APPROACH TO PEDIATRIC PULMONARY

DISEASES

Emily B. Gaerlan-Resurreccion, MD

Pediatric Pulmonologist

A one year old boy is brought to the emergency room for respiratory distress. He was noted to have cough for about one week prior to consult.

Pediatric HistoryRespiratory symptoms

dyspnea cough pain wheezing

Pediatric HistoryRespiratory symptoms

snoring apnea cyanosis

Pediatric HistoryRespiratory symptoms• chronicity• timing during day or night• associations with activities such

as exercise or food intake

Pediatric HistorySystem Review

cardiac gastrointestinal central nervous hematologic immune systems

Pediatric HistoryFamily History

similar symptoms or any chronic disease with respiratory components

Physical ExaminationObservation

Respiratory Rate Presence of grunting Breathing patterns Presence of stridor

Age Respiratory rate

Premature 40 – 70

0 – 3 months 35 - 55

3 - 6 months 30 – 45

6 - 12 months 25 – 40

1 - 3 years 20 - 30

3 - 6 years 20 – 25

6 - 12 years 14 – 22

>12 years 12 - 18

Physical ExaminationObservation

Restrictive Disease: shallow breathsObstructive Disease: slow, deep

breathsExtrathoracic: inspiratory

stridorintrathoracic: expiratory

stridor

Physical ExaminationPercussion

• limited value in small infants• percussion is usually dull in

restrictive lung disease and with a pleural effusion, pneumonia, and atelectasis,

• tympanitic in obstructive disease (asthma, pneumothorax)

Physical ExaminationAuscultation

• confirms the presence of inspiratory or expiratory prolongation

• provides information about the symmetry and quality of air movement.

• detects abnormal or adventitious sounds


• stridor - a predominant inspiratory monophonic noise

• crackles - high pitch, interrupted sounds found during inspiration and more rarely during early expiration, which denote opening of previously closed air spaces


• wheezes - musical, continuous sounds usually caused by the development of turbulent flow in narrow airways

Physical Examination

Digital clubbing• sign of chronic hypoxia but may be

due to nonpulmonary etiologies• Measured by phalangeal depth

ratio, hyponichial angle and Schamroth’s sign

Diagnostic Tests

Arterial blood gas• the single most useful rapid test of

pulmonary function • overall assessment of the functional

state of the respiratory system and clues about the pathogenesis of the disease

Diagnostic Tests

TRANSILLUMINATION OF THE CHEST

• In infants up to at least 6 mo of age • Used in the diagnosis of pneumothorax• results in an unusually large halo of

light in the skin surrounding the probe.

Diagnostic Tests

CHEST ROENTGENOGRAMS • posteroanterior and a lateral view

(upright and in full inspiration) • If pleural fluid is suspected,

decubitus films are indicated.

Diagnostic TestsUPPER AIRWAY FILM • upper airway obstruction and

particularly about the condition of the retropharyngeal, supraglottic, and subglottic spaces

Diagnostic TestsSINUS AND NASAL FILMS • uncertain use• Imaging studies are not necessary

to confirm the diagnosis of sinusitis in children <6 yr.

• CT scans are indicated if surgery is required in sinus infections

Diagnostic TestsCHEST CT AND MRI • CT delineates the internal structure of

the thorax in much greater detail

• MRI is an excellent procedure to delineate hilar and vascular anatomy

Diagnostic TestsFluoroscopy

evaluating stridor and abnormal movement of the diaphragm or mediastinum

Aid in needle aspiration or biopsy of a peripheral lesion

Diagnostic TestsBARIUM SWALLOW

recurrent pneumonia persistent cough of undetermined

cause stridor persistent wheezing gastroesophageal reflux

Diagnostic TestsBRONCHOGRAPHY

Diagnosis of suspected bronchiectasis or airway anomalies

instilling contrast material directly into the airway

CT and MRI have largely replaced bronchography

Diagnostic TestsPULMONARY ARTERIOGRAPHY

AND AORTOGRAMS evaluation of the pulmonary

vasculature vascular rings and suspected

pulmonary sequestration Replaced by Real-time and Doppler

echocardiography and thoracic CT with contrast

Diagnostic TestsRADIONUCLIDE LUNG SCANS

evaluating pulmonary embolism and congenital cardiovascular and pulmonary defects

replaced by spiral reconstruction CT with contrast medium enhancement

Diagnostic TestsPULMONARY FUNCTION TESTING

define the type of process (obstruction, restriction)

define the degree of functional impairment

Used in following the course and treatment of disease


Used in estimating the prognosis of disease

preoperative evaluation and in confirmation of functional impairment in patients having subjective complaints but a normal physical examination


plethysmography spirometry diffusing capacity for carbon

monoxide (DLCO)

Restrictive lung disease

• decrease total lung capacity(TLC )

• decreases vital capacity

Obstructive lung disease

• increase residual volume and FRC

• produce gas trapping

MICROBIOLOGY: EXAMINATION OF LUNG SECRETIONS

• Nasopharyngeal or throat cultures • by nasotracheal aspiration • by transtracheal aspiration

through the cricothyroid membrane


• by a sterile catheter inserted into the trachea either during direct laryngoscopy or through an endotracheal tube


Sputum specimen

• presence of alveolar macrophages (large, mononuclear cells) is the hallmark of tracheobronchial secretions.


Sputum specimennasopharyngeal and tracheobronchial secretions : ciliated epithelial cells

Nasopharyngeal and oral secretions : squamous epithelial cells


Gastric aspirate • suitable for culture for acid-fast bacilli• During sleep, mucociliary transport

continually brings tracheobronchial secretions to the pharynx, where they are swallowed


Wright-stained smear of sputum or bronchoalveolar lavage (BAL) fluid bacterial : PMN leukocytes

allergic disease : Eosinophils viral : intranuclear or cytoplasmic

inclusion bodies

fungal : Gram or silver stains

EXERCISE TESTING

• for detecting diffusion impairment

• assessment of the patient's exercise tolerance

SLEEP STUDIES

• Polysomnographic studies • Diagnosis of obstructive sleep

apnea or hypoventilation during sleep

• Diagnosis of disorders of respiratory control

LUNG VISUALIZATION AND LUNG SPECIMEN–BASED

DIAGNOSTIC TESTS

LARYNGOSCOPY

• performed with either a rigid or a flexible instrument

• evaluation of stridor, problems with vocalization, and other upper airway abnormalities

BRONCHOSCOPY AND BRONCHEOALVEOLAR

LAVAGE (BAL)

Bronchoscopy :inspection of the airways

BAL :used to obtain a representative specimen of fluid and secretions from the lower respiratory tract

Indications for diagnostic bronchoscopy and BAL

• recurrent or persistent pneumonia • atelectasis • unexplained or localized and

persistent wheeze • the suspected presence of a foreign

body • hemoptysis

Indications for diagnostic bronchoscopy and BAL

• suspected congenital anomalies• mass lesions• interstitial disease • pneumonia in the

immunocompromised host

Indications for therapeutic bronchoscopy

and BAL

• bronchial obstruction by mass lesions

• foreign bodies or mucous plugs• general bronchial toilet• bronchopulmonary lavage

Rigid bronchoscopy

• ventilation is accomplished through the scope

• for the extraction of foreign bodies, for the removal of tissue masses, and in patients with massive hemoptysis

Flexible bronchoscopy

• ventilation around the flexible scope

• can be passed through endotracheal or tracheostomy tubes

Flexible bronchoscopy • can be introduced into bronchi

that come off the airway at acute angles

• can be safely and effectively inserted with topical anesthesia and conscious sedation

Complications related to sedation transient hypoxemia laryngospasm Bronchospasm cardiac arrhythmias

Complications

Iatrogenic infection bleeding pneumothorax pneumomediastinum

THORACOSCOPY pleural cavity can be examined thoracoscope is inserted through an

intercostal space lung is partially deflated allows the operator to view the surface of the lung, the pleural surface of the mediastinum diaphragm and parietal pleura

THORACOSCOPY Indications: endoscopic lung biopsy pleural biopsy bleb resection pleural abrasion ligation of vascular rings

THORACENTESIS

For diagnostic or therapeutic purposes

fluid is removed from the pleural space by needle

THORACENTESIS Complications include infection pneumothorax bleeding

Transudates vs. Exudates

Transudates result from mechanical

factors influencing the rate of formation or reabsorption of pleural fluid and generally require no further diagnostic evaluation

Transudates vs. Exudates

Exudates result from inflammation or

other disease of the pleural surface and underlying lung and require a more complete diagnostic evaluation

PERCUTANEOUS LUNG TAP

most direct method of obtaining bacteriologic specimens from the pulmonary parenchyma

only technique other than open lung biopsy not associated with at least some risk of contamination by oral flora

PERCUTANEOUS LUNG TAP

Major indications for a lung tap roentgenographic infiltrates of

undetermined cause those unresponsive to therapy in

immunosuppressed patients who are susceptible to unusual organisms

LUNG BIOPSY only way to establish a diagnosis,

especially in protracted, noninfectious disease

thoracoscopic or open surgical biopsies

Thank you

Documents

APPROACH TO PEDIATRIC PULMONARY DISEASES Emily B. Gaerlan-Resurreccion, MD Pediatric Pulmonologist