Respiratory Diseases

1. Respiratory Diseases Lin Guangyu Department of Pediatrics, The Second Affiliated Hospital to Medical College, Shantou University

2. General Introduction • Respiratory diseases that include inflammation of upper and lower respiratory tract, allergic diseases, pleura diseases, foreign body, pulmonary tumors and congenital disorders is a significant cause of death and chronic illness in children. • Pediatric pulmonary diseases account for almost 50% of deaths in children under age 1 year and about 20% of all hospitalization of children under age 15 years.

3. General Introduction • Respiratory infections are the most frequently occurring illness in childhood. • Pneumonia accounts for almost 28% of deaths in children under age 5 years. • Approximately 7% of children have some sort of chronic disorder of the lower respiratory system

4. Pneumonia

5. Classification • Classified by anatomy • Lobar Pneumonia • Bronchopneumonia • Interstitial Pneumonia • Bronchiolitis

6. Classification • Classified by etiology • Viral Pneumonia • Respiratory Syncytial Virus (RSV ) • Adenovirus • Rhinoviruses • Parainfluenza or influenza viruses • Enteroviruses • Cytomegalovirus (CMV) • Measles virus

7. Human metapneumovirus • Human bocavirus • SARS coronavirus

8. About Human Metapneumovirus • It is classified by paramyxovirus. • It is about over 10% of all children with respiratory infection in winter. • It is nearly not covert infection at all. • It is one of the most important pathogens that cause the wheeze. • It is mainly cause bronchopneumonia and bronchiolitis.

9. About Human Bocavirus • It is classified by parvoviridae. • It is about 1.5~11.3% of all children with respiratory infection. • It is one of the most important pathogens that cause the wheeze. • It is mainly cause bronchopneumonia and bronchiolitis. • Is it a pathogen?

10. Aboutcoronavirus Type 1 —— Mammal Type 2 —— Mammal Type 3 —— Aves Type 4 —— SARS Coronaviruses

11. Classification • Bacterial Pneumonia • Gram-positive coccus • Streptococcus Pneumoniae • Staphylococcus aureus ,CNS! • Gram-negative bacillus • Pneumobacillus • Escherichia coli • Pseudomonas • Haemophilus influenzae • Klebsiella • Legionella pneumophila • Anaerobe

12. Classification • Mycoplasmal pneumonia • Mycoplasma pneumoniae • Chlamydial pneumonia • Chlamydia • Fungal Pneumonia • Cryptococcus • Candida • Coccidioides • Histoplasma

13. Classification • Protozoal pneumonia • Pneumocystis Carinii • Noninfectious pneumonia • Inhalation Pneumonia • Eosinophilic pneumonia

14. Classification • Classified by course • Acute Pneumonia: <1 month • Deferred Pneumonia: 1～3 months • Chronic Pneumonia: >3 months

15. Classification • Classified by patient’s condition • Mild pneumonia • Severe pneumonia

16. Classification • Others • Typical pneumonia • Atypical pneumonia Pneumonia caused by SARS coronavirus • Community acquired pneumonia (CAP) • Hospital acquired pneumonia (HAP)

17. Bronchopneumonia

18. Introduction • Bronchopneumonia, accounting for 24.5%～56.2% of all hospitalizatons of children, is the most frequently occurring illness in childhood. • The incidence is higher in early childhood than in any other period of life. • There are significant difference in the incidence of bronchopneumonia by season and geographic region.

19. Etiology • Most pneumonia in children are caused by viruses and bacteria. • Viruses • RSV • Parainfluenza viruses (1, 2 and 3) • Influenza viruses (A and B) • Adenovirus • RSV, parainfluenza and influenza are responsible for more than 75% of cases.

20. Etiology • Bacteritic • Streptococcus Pneumoniae (the most common cause of bacterial infection) • Staphylococcus aureus ,CNS • Haemophilus influenzae • Klebsiella • Pneumobacillus • Escherichia coli • Pseudomonas • Mycoplasma pneumoniae

21. Different organisms affect different age groups Age Bacterium Virus others 1d-20d Group B H Streptococcus Cytomegalovirus Gram-negative bacilli(E.coli) 3w-3m Streptococcus pneumoniae RSV Chlamydia trachomatis Bordetella pertusssis Parainfluenza virus Staphylococcay aureus 4m-4y Streptococcus pneumoniae RSV Mycoplasma pneumoniae Haemophilus influenzae Parainfluenza virus Mycobacterium tuberculosis Influenze virus Adenovirus Rhinoviruses 5y-15y Streptococcus pneumoniae Mycoplasma pneumoniae Chlamydial pneumonice

22. Etiology • Other causes • Age • Season of the year • Immune status of the host • Environmental factors

23. Pathology • Inflammatory cell infiltration, exudate, edema and localized hemorrhage of bronchiolar submucosa, Interstitium, alveoli, Interalveolar septa and lymphatic vessels • Necrosis of bronchiolar and alveolar epithelium • Hyperinflation or collapse of the distal lung tissue

24. Pathology • Lesions of viral or bacterial infection result in tracheitis, bronchitis, interstitial pneumonia and lobuli pneumonia. • Interstitial involvement is relatively common in viral pneumonia. • Bacterial pneumonia is characterized by the presence of damages of lung tissue.

25. Pathophysiology • Respiratory disorder (acute respiratory failure) • Ventilation and /or perfusion disorder (V/Q mismatch) • Diffusion defects • Intrapulmonary shunt

26. Pathophysiology • Circulatory disorders • Viral and/or toxipathic myocarditis • Pulmonary hypertension • Heart failure • Circulatory failure ( shock) • Disseminated intravascular coagulation (DIC)

27. Pathophysiology • Anomalies of central nervous system • Cerebral edema (toxic encephalopathy) • Hypoxemia • Hypercapnia • Metabolic Acidemia • Energy metabolism disorder • Toxin

28. Pathophysiology • Anomalies of Alimentary system • Toxic enteroparalysis • Gastrointestinal bleeding • Hypoxemia and hypercapnia • Abnormalities of electrolyte balance • Toxaemia • shock • Acute stress ulcer • Hepatic injury

29. Pathophysiology • Acute renal failure • Adrenal crisis (insufficiency) • Abnormalities of water, electrolyte and pH balance SIRS→MODS→MOF

30. Bronchia mucosa edema Alveolus edema air exchange air entry Respiratory failure Metabolic acidosis Respiratory acidosis toxic encephalopathy Gastrointestinal breeding Heart failure Toxic enteroparalysis Toxaemia

31. Clinical Manifestations • Symptoms and sings • General symptoms and sings • Fever • Body temperature is higher in bacterial infection than viral infection • Hypothermia (infant) • symptoms and sings of generalized toxicity • Myalgia, Malaise and headache

32. Clinical Manifestations • Symptoms of respiratory system • Cough • Dry cough • Productive cough • Tachypnea • Dyspnea • Rapid, shallow respirations( 40～80/ min) • Nasal flaring • Intercostal, subcostal, and suprasternal retraction • Cyanosis • Respiratory fatigue

33. Clinical Manifestations • Signs of respiratory system • Widespread moist rales and wheezing • Signs of substantial variations • Decreased breath sounds • Dullness to percussion • diminished tactile or vocal fremitus • Bronchial breath sounds

34. Clinical Manifestations • Severe Pneumonia • Circulatory system • Rival or toxic myocarditis • Heart failure

35. Heart failure • Rapid, shallow respirations≥60/min • Rapid heart rates ≥180/min • Dyspnea with intercostal and subcostal retractions, cyanosis, pale and gray of face , irritability, and peripheral pallor • Muffled and distant heart sounds, and a gallop rhythm • Liver enlargement • Edema of the face and extremities,oliguria or anuria

36. Clinical Manifestations • Nervous system • Toxic encephalopathy • Alimentary system • Toxic enteroparalysis • Gastrointestinal bleeding • DIC • SLADH • MODS

37. Complications • Empyema • Pneumothorax • tension pneumothorax • Pyopneumothorax • Pneumatocele

38. Laboratory Test • Tests for etiologic agent • Bacterial culture • Blood culture • Culture of material from the respiratory tract secretion • Culture of Pleural effusion • Other culture

39. Laboratory Test • Laboratory diagnosis of viral infections • Antigen or nucleic acid detection • Isolation of viruses by culture of the respiratory tract secretions • Use of special antibodies

40. Laboratory Test • Isolation and culture of other etiologic agent • Mycoplasma pneumoniae • Chlamydia • Fungi • Specific antibody detection on the pathogens • Tests of molecular biology • DNA probs • Polymerase chain reaction (PCR)

41. Laboratory Test • Blood test • White blood cell counts • Bacterial pneumonia ↑↓ • Rival pneumonia↓ • NBT test • NBT-positive cells>10% • C-reactive protein (CRP) • CRP ≥15μg/ml • Blood gas analysis

42. Chest X-ray Findings • Perihilar streaking • Increased interstitial markings • Peribronchial cuffing • Patchy infiltrates in the lung • Development of pneumatoceles • Hyperinflation of the lung • Atelectasis • Lobar consolidation (as in bacterial pnuemonia) • Radiographic findings of pleural effusion

46. Diagnosis and Differential Diagnosis • Diagnosis • According to symptoms, signs, and Radiographic findings, bronchopneumonia are easily diagnosed. • A key decision in evaluating children with bronchopneumonia is to determine whether the illness is mild or severe, or whether a secondary infection or complication is present

47. Diagnosis and Differential Diagnosis • Differential Diagnosis • Acute bronchitis • Pulmonary tuberculosis Acute miliary tuberculosis of the lungs • Foreign body in bronchus

48. Acute bronchitis

49. Acute miliary tuberculosis of the lungs

50. Acute miliary tuberculosis of the lungs