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Infection Diseases of Infection Diseases of Respiratory System in ChildrenRespiratory System in Children

IntroductionIntroduction

High Morbidity RateHigh Morbidity Rate

High Mortality RateHigh Mortality Rate

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.

Acute and Chronic Infection

Rheumatic Disease

Pleural Disease

Foreign Body of Airway

Neoplasm

Congenital Anomalies

Cricoid cartilage

Venting, , Warming, , Humidification

and conditioning

ventilation

Upper respiratory tractUpper respiratory tract ： nose, paranasal sinuses pharynx, eustachian tube, epiglottis, larynx

Lower respiratory tractLower respiratory tract:: trachea, , bronchi, , bronchioles, , alveolus

Anatomy and Anatomy and PhysiologyPhysiology

Anatomy and Anatomy and PhysiologyPhysiology

Upper Upper respiratory respiratory tracttract

Short Short Nasal passages, nasolacrimal duct and eustachian tubeNasal passages, nasolacrimal duct and eustachian tube

Significance :These characters make nasal cavity easy to become hyperemia, edema, and congestion which will induce infection. Local infection can spread to nearby organs and tissues easily and cause dyspnea, hoarseness and apnea.

Nasal mucosaNasal mucosaIs softIs soft

More vascularMore vascular Nasal cavity Nasal cavity is short and is short and

narrow narrow

Anatomy and Anatomy and PhysiologyPhysiology

Narrowed airwayNarrowed airwaySoft mucous menbraneSoft mucous menbraneMore vascularMore vascularSofter and more compliantSofter and more compliant pulmonary alveolisIgA on sIgA on Respiratory Mucosaalveolar surfactant

Clinical significance:

Easy to become hyperemia, edema, and congestion Easy to become hyperemia, edema, and congestion

which will induce infectionwhich will induce infection

Complication: Pulmonary emphysema and atelectasisComplication: Pulmonary emphysema and atelectasis

Lower Lower respiratory respiratory tracttract

Small Small amountsamounts

Anatomy and Anatomy and PhysiologyPhysiology

The younger the child The younger the child The quicker the frequencyThe quicker the frequencyThe less regular the rhythmThe less regular the rhythm

Vital capacity (VC)Vital capacity (VC)

Tidal volumeTidal volume

Total lung capacity (TLC)Total lung capacity (TLC)

Respiratory frequency and rhythm ：The respiratory frequency is inversely related to ageThe respiratory frequency is inversely related to age ..

⑴ neonate : 40 ～ 50 bpm ； 6 ～ 12mo: 30-35 bpm ； 1-3 yr : 25 ～ 30 bpm ； 4 ～ 9 yr : 20-25 bpm ； 8-14 yr :18 ～ 20 bpm 。(2) Some young infants present with irregular rhythm or apnea due to immature respiratory center.

Small

Anatomy and Anatomy and PhysiologyPhysiology

Thoracic cageThoracic cage The thorax is barrel shaped. The ribs are in horrizontal he ribs are in horrizontal

position which are almost position which are almost perpendicular to the spinal perpendicular to the spinal column. The location of diaphragm is oppositely column. The location of diaphragm is oppositely superior, which make the size of thoracic cavity superior, which make the size of thoracic cavity decrease, and the size of lung increase.decrease, and the size of lung increase.

Respiratory immune functionRespiratory immune function The specific and nonspecificnonspecific immune function are poor.

Acute Upper Respiratory Tract Infection Acute Upper Respiratory Tract Infection AURIAURI

commonly called ““ common cold”common cold”

Acute Upper Respiratory Acute Upper Respiratory InfectionInfection

IntroductionIntroduction

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 pertussi

s may also follow AURI

90% of AURI are

caused by viral

infection

Etiology

Rhinovirus

Echo virus

Coxsackievirus

Parainfluenza

Influenza

Adenovirus

RSV(Respiratory Syncytial Virus)

PneumococcusMoraxelle catarrhalis

Haemophilus influenzae

Staphylococcus aureus

BacteriaBacteria

Mycoplasma

Chlamydia

Other Microorganisms

OthersOthers

Mild symptomMild symptom

Nasal congestion, rhinorrhea,

sneezing, sore throat

Severe symptomSevere symptom

High fever, convulsion, anorexia,frequency cough

Mild symptomMild symptom

Nasal congestion, rhinorrhea,

sneezing, sore throat

Severe symptomSevere symptom

High fever, convulsion, anorexia,frequency cough

Clinical ManifestationClinical Manifestation

Symptoms of URI in children Symptoms of URI in children of different agesof different ages

< 3 mo Infants AdolescentsSystemicsymptom

Usually mildLow grade fever

Usually severeHigh feverConvulsionIrritability

Usually mildLow grade fever

Respiratory Symptoms

Nasal congestion Dyspnea

Absent or mildor severe

Nasal congestionRhinorrheaSneezingSore throat

Gastrointestinal Symptoms

DiarrheaVomiting

DiarrheaVomitingAnorexia

Abdominal Pain

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

variety of skin rashes

Physical SignPhysical Sign

HerpanginaCoxsackievirus AMost often occurs in summer and autumnMore 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 ulcersDuration of illness is usually 7 days

Two Special TypeTwo Special Type

Occurs typically with type 3,7 adenovirus

Most often occurs in spring and summer

Children （ >3 yr ） more often affected

Features include:

A high temperature that lasts 4–5 days, pharyngitis,

conjunctivitis, cervical lymphadenopathy, and rhinitis.

Duration of illness is usually 1-2 weeks

Pharyngoconjunctival FeverPharyngoconjunctival Fever

Otitis mediaCervical lymphadenitisBronchitisPneumoniaSepticemia

Complication Complication

Viral Infection

→ → Viral Myocarditis Viral Encephalitis

Bacterial Infections （ streptococcus))

→ → Acute Nephritis Rheumatic Fever

DiagnosisDiagnosis

Clinical manifestations

Symptoms and sighs

The differential diagnosis of the URl includes other acute infectious disease.

In patient with In patient with febrile convulsion, central nervous system Infections should also considered.

Patients with abdominal pain may have acute abdomen.

Differential diagnosisDifferential diagnosis

Difference Between Mesenteric Lymphadenitis Difference Between Mesenteric Lymphadenitis and and Acute appendicitisAcute appendicitis

Clinical Manifestation

Mesenteric lymphadenitis Acute appendicitis

Symptom of URI exist absent

Fever andAbdominal Pain

1st present with: feverFollow : pain (mild)

1st present with : pain (severe)Follow : Low grade fever

Abdomen signs Diffuse tendernessNo rebound tenderness and guarding

Progressive localized abdominal tendernessWith rebound tenderness and guarding

Blood routine WBC is usually normal or elevated

WBC is elevatedhigher level of neutrophils

ProphylaxisProphylaxis

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

General treatment Etiological treatment Anti-virus ： Ribavirin Avoid the abuse of antibiotics

Symptomatic treatment Severe nasal obstruction Irritability-restlessness High fever Pharyngeal portion ulcer Conjunctivitis

TreatmentTreatment

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.

SummarySummary

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.

Acute BronchitisAcute Bronchitis

Infectious factors ： viral, 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 factors ： immunodeficiency, nutritional diseases, specific body constitution.

EtiologyEtiology

Clinical ManifestationClinical 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

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.

SummarySummary

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.

Acute PneumoniaAcute Pneumonia

Season of onsetSeason of onset

Age of onsetAge of onset

Morbidity rateMorbidity rate

Mortality rateMortality rate

EpidemiologyEpidemiology

Classified according to the infecting organism:Classified according to the infecting organism: Viral pneumonia, bacterial Pneumonia, mycoplasma

Pneumonia.Classified according to Pathology:Classified according to Pathology: Bronchopneumonia, lobar pneumonia,interstitial

pneumonia.Classified according to duration of disease:Classified according to duration of disease: Acute pneumonia(<1 mo), persistent pneumonia(1-3 mo)

and chronic pneumonia(> 3mo).Classified according to severity of disease:Classified according to severity of disease:

Mild pneumonia and severe pneumonia.

CategoryCategory

BacteriaBacteriaStreptococcus pneumoniae, Haemophilus

influenzae, Staphylococcus aureus, Escherichia coli, Pseudomonas pyocyanea

Viruses Respiratory Syncytial Viruses,

adenovirus, influenza, parainfluenza

othersIncidence rate of Chlamydia pneumoniae

and Mycoplasma pneumoniae are

increasing recent years.

EtiologyEtiology

AgeAge More often in infants

Disease

Environment

Malnutrition, Congenital heart disease,

Immunodeficiency disease

The recidence is wetness, stuffiness and crowding.

InducementInducement

Patients with the following problems are particularly predisposed to this disease:

Hyperemia, edema and

inflammatory infiltration of lung

tissues

Alveolar exudate

Patchy Inflammation focus,

and consolidation

Atelectasis and emphysema

of lung

PathologyPathology

FeveFeverr

coughcough

tachypnetachypneaa

RalesRales

fourfour

symptomssymptoms

ClinicalClinical ManifestionManifestion

pneumoniapneumonia

Apart from the general features of bronchopneumonia, Apart from the general features of bronchopneumonia,

severe pneumonia also present with systemic toxic severe pneumonia also present with systemic toxic

symptoms in respiratory system, circulatory system, symptoms in respiratory system, circulatory system,

nervous system and digestive system.nervous system and digestive system.

Severe PneumoniaSevere Pneumonia

Circulatory system Myocarditis, heart failureMicrocirculation disturbance

Digestive system Gastrointestinal dysfunction, enteroplegiaAlimentary tract hemorrhage

Nervous system Intracranial hypertensionEncephaledema

Water-Electrolyte Balance

Mixed acidosis, dehydrationHyponatremia

Extrapulmoanry Extrapulmoanry presentationspresentations

Suddenly onset of tachypnea, R>60 bpm, increased pulmonary rales.

Tachycardia that can not be explained by high fever or tachypnea, HR>180 bpm

Irritability and cyanosis

Gallop rhythm or dull heart sound , distension of jugular vein and enlarged cardiac

Increased liver with tenderness, > 1.5cm.

Oliguria or anuria that present with edema of eyelid or lower extremities.

Myocardial failureMyocardial failure

Empyema of pleura Purulent pneumothorax Bullae of lung

Others ： Septicemia Purulent pericarditis

ComplicationComplication

Peripheral blood examination 　　　　　　　　 White cell count CRP (C-reactive protein) Nitroblue tetrazolium testEtiological examination

Bacteriological examination ： Bacterial culture Virological examination ： Viral isolation Examination of mycoplasma ： Specific immunity examination

Laboratory Laboratory ExaminationExamination

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

Increase lung markingsIncrease lung markings

Diffuse bilateral Patchy infiltrates and Diffuse bilateral Patchy infiltrates and consolidation scattered throughout both consolidation scattered throughout both lungslungs

Atelectasis, hyperinflation, bullae of lung and pyothorax

Chest radiographic findings in bronchopneumonia

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

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.

Lobar pneumonia

Pathogen: maily streptococcus pneumoniae

Pathology : inflammtion infiltrates throughout a whole lobe or infiltrates throughout a whole lobe or

segment of the lung.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.

Lobar pneumonia at Lobar pneumonia at middle lobe of right lungmiddle 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,

viral disease, RSV (85%).

aged 2-6 months.

airway obstruction is due to pathological changes include

swelling and distension of bronchioles, secretions block

age.

BronchiolitisBronchiolitis

expiratory wheezing

tachypnea, nasal flaring

Cyanosis

fine rales

emphysema

The duration of illness is 4 ~ 7 days

expiratory wheezing

tachypnea, nasal flaring

Cyanosis

fine rales

emphysema

The duration of illness is 4 ~ 7 days

Clinical ManifestationClinical Manifestation

Hyperexpansion is commonly present

Peribronchial cuffing

Increased interstitial markings

Patchy infiltrates

Hyperexpansion is commonly present

Peribronchial cuffing

Increased interstitial markings

Patchy infiltrates

Chest radiographic findingsChest radiographic findingsChest radiographic findingsChest radiographic findings

Frontal views of CXR:

Ground-glass opacity Decreased lung markingsPatchy infiltrates in innner and middle zoneAcquired hyperinflation

RSV PneumoniaRSV Pneumonia

Escherichia coli is the most common pathogen in neonate. In young

infants > 1 week, mainly pathogen are staphylococcus aureus and

hemolytic streptococcus. Some patients may present only with signs of Some patients may present only with signs of

generalized toxicity.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.

Pneumonia of newbornPneumonia of newborn

Chest X-rayChest X-ray

Frontal views :

There is patchy shadows and infiltrates at right lung field.

Adenovirus pneumoniaAdenovirus pneumonia Type 3,7 adenovirusYoung children （ 6 mo-2 yr ） are more often

affectedAcute 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

daysPatchy infiltrates and consolidation with

hyperinflation.

Adenovirus pneumoniaAdenovirus pneumonia

Frontal views :

Chest radiographs reveals

diffuse interstitial and patchy

alveolar infiltrates,

peribronchial thickening, and

focal consolidation

throughout both lung field.

Staphylococcal pneumoniaStaphylococcal pneumonia

More common in neonate and infantsMore common in neonate and infants Present a sudden onset and progress quicklyPresent a sudden onset and progress quickly Signs include: Signs include: rashes, severe toxic symptoms,

digestive symptoms, convulsion and shockSigns vary with stage of diseaseConsolidation of lung is obviousChest X-ray reveals infiltrates, abscess and bullae

of lung

Abscess of lung

Frontal views :

Multiple round high density shadow in both sides

PyopneumothoraxPyopneumothorax

Encapsulated pleural effusion

Pulmonary Bulla

Female ， 7 day ， hyperpyrexia and no crying

CXR: multiple giant

air-containing cavity

Common cause of symptomatic pneumonia in older children

Fever, dry cough are common symptoms Extrapulmonary complications sometimes

occurChest radiographs are untypical, usually

demonstrate interstitial or bronchopneumonic infiltrates

Mycoplasma pneumoniaMycoplasma pneumonia

Interstitial infiltrates in Interstitial infiltrates in Mycoplasma Mycoplasma

pneumoniapneumonia

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

Peak age of onset

Clinical manifestation

Laboratory examination

X-ray examination

Others

DiagnosisDiagnosis

Acute bronchitisAcute bronchitis

Pulmonary tuberculosisPulmonary tuberculosis

Foreign body in bronchusForeign body in bronchus

Differential DiagnosisDifferential Diagnosis

Nursing and Nursing and supporting therapySymptomatic treatment ：： Oxygen supply Conscious sedation Pyretolysis Cough suppressants Eliminate sputum Antimicrobial therapy Treatment of complicationEnhance immunity functionphysical treatment

TreatmentTreatment

Principle of antibiotic treatment:Principle of antibiotic treatment:

Sensitive

Early treatment

Sufficiency

Drug combination

Antimicrobial treatment

Antibiotic treatment

Streptococcus pneumoniae penicilin Amoxicillin

Bacillus influenzae Amoxicillin plus clavulanate2nd or 3rd-generation cephalosporins

Staphylococcus aureus Oxacillin sodium Vancocin

Moraxelle catarrhalis Amoxicillin plus clavulanate

Mycoplasma Pneumonia Erythromycin Macrolide

Antiviral treatmentAntiviral treatment

There is no ideal drug in antiviral therapy.There is no ideal drug in antiviral therapy.

Ribovirin

interferon (IFN)

Human Immunoglobulin

Traditional chinese drug therapy

Yuxingcao, Double coptis

Severe Severe toxic symptom that include shock, ultrahyperpyrexia and toxic encephacopathy

Increased Increased secretions and and bronchial spasm

Complicated with Complicated with pleural effusion in early periodin early period

Indication of Indication of Systemic corticosteroidsSystemic corticosteroids

Heart failure ：： cardiotonic, sedative diuresis and oxygen supplyRespiratory Failure ：： suctioning, oxygen supply intubation and artificial respiratorToxic encephacopathy ：： anti-infection, oxygen supplY, correct acidosis

Treatment of severe Treatment of severe pneumoniapneumonia

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.

SummarySummary

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