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History of swelling over face or feet or abdomen indicates Hypoproteinemia causing loss of â€¦â€¦ force in plasma and resulting edema. The pleural effusion is a part of this systemic edema.
Acute onset of fever, chest pain, cough and breathlessness suggests infection involvement of pleura. This infection can be bacterial, usually with accompanying pneumonia and the clinical picture is usually 'hot'.
Similar sub acute presentation may be seen in tubercular pleurisy with effusion in which the clinical picture is dominated by fever and chest pain. Respiratory distress in less. The patient is usually 'cold' However, the use of pleural effusion is large.
History suggestive of tubercular pleural effusion:
H/O contact of patient with an open case (spectrum positive or somebody who has taken â€¦â€¦â€¦. Treatment at Govt. Hospital for 6 mo; H/O blood in spectrum; H/O abnormal chest X ray)
H/O chronic cough > 4 wks
H/O fever > 2 wks
H/O unexplained weight loss or failure to grow normally
Family H: Contact with an infectious family member or visitor with tuberculosis. Even occasional contact is important
Socioeconomic H: Tuberculosis is common in low SE status. Empyema is common in modequately treated, poor and malnourished children.
Diet H: Adequate food intake but failure to grow/gain weight is suggestive of tuberculosis.
Developmental history: Delayed development, mental retardation and cerebral palsy impair the ability to handle oral secretions causing recurrent pneumonia and its complications.
Past history/treatment history: H/O tapping for pleural fâ€¦â€¦.; scar of chest tuber; documents regarding diagnosis, treatment; compliance with the advised treatment. Patient with pneumonia not responding to antibiotics; Patient with pneumonia getting sicker and tâ€¦.. despite appropriate antibiotics.
Immunization H: especially for BCG and measles.
General Physical Examination (GPE): It tells about the etiology and severity.
Well or sick looking
Respiratory distress, if any
Oxygen Mask; chest tube with drainage bag; scar
Puffiness of face, edema feed and/or asâ€¦â€¦.. (indicates transudative effusion
Cyanosis / Anemia / Lymphadenopathy / Jaundice/ Rash.
(severe resp. dispess) with chronic disease / malnutrion) (S/O tuberculosis / mâ€¦â€¦..) (drug side effect / /H or associated) (Post measles brawny desquamation)
Anthropometry: Evidence of acute or chronic or acute on chronic malnutrition: Seen in tuberculosis etiology but may be seen associated with Empyema.
Respiratory System: For confirmation and extent of pleural effusion:
Re inspect chest:
1. Respiratory rate
2. Asymmetry of movement (discard side mover less than healthy side)
3. Trail sign: Prominent Stern mastoid on unaffected side
4. Scars 3 Bulging of intercostals space in large effusion
1. Location of apex beat (displaced due to mass effect of a large effusion)
2. Decreased chest movement on affected side
3. Palpable pleural rub
Percussion: Dullness to percussion on affected side
Auscultation: Diminished air entry (Absent breath sounds) over the region of effusions.
Diminished VF, VR
Plural rub (scratchy sound) may be heard Aegophony, bronchophony and whispering pectoriloguy may be appreciated.
Hb - Low in malnutrition; chromic infection (tuberculosis).
TLC - Raised in acute bacterial infections
DLC - Neutrophilia in bacterial infection, lymphocytosis in tuberculosis
ESR - Raised in tuberculosis / acute bacterial infections
Chest X-ray: Confirmation of diagnosis; location & size of effusion
Ultrasound Chest: Localizes fluid for topping small effusion; located effusions.
Pleural tap & pleural fluid examination: Defines the type of effusion: Transudate / exudates; Tubercular; bacterial infected - complicated or Empyema.
Antibiotics for sympheumonic effusions & simple par pneumonic effusions
Chest tube drainage for complicated par pneumonic effusions and Empyema
ATT (Anti tubercular treatment) for tubercular effusions
High Calories, high protein diet.
Discussion and viva voice
Difference between transudative and exudatice pleural effusions
Ref. H-Pg. 1658
Plural fl. protein
Pl. fluid LDH
Pl. fluid LDH
>2/3 of normal upper limit
Plural fluid Cholesterol
Syn/dl for serum
If the serum protein to pleural fluid protein gradient (difference) is more than 3.1 g/dL, then the effusion is usually transudative, though one of the above criteria may be met otherwise, one criteria as given in table is enough to call the effusion exudative.
Test to be done in an exudative pleural effusion
Ceram stainly; all count & type (differential cell all count) culture & sensitivity
Stages of pleural effusion of bacterial cause:
Simple par pneumonic
Complicated par pneumonic
G > 60
PH > 73
Glucose < 35
PH < 7.2
LDH > 1000
Gram stain & culture â€¦.
May be positive
May be positive
No drainage reg.
Thus can be drained by needle and syringe but if drainage is not complete, tube thoracostomy (damage is needed. H-1659
Tuberculosis Plural effusions: All tuberculosis effusions are due to discharge of mycobacteria, into the pleural space, by subpleural pulmonary focus of subpleural caseous lymph node.
T.B. of Pediatric infectious disease by Feigin, Kaplan etal
The diagnosis is established by high levels & tuberculosis morkese in pleural fluid (Adenosine deaminase ADA > 40IV/L, interferon Y > 140pg/ml or positive PCR for tuberculosis DNA). The recommended treatment is same for both pulmonary & pleural TB (H-1659) Vol. 11.
Radiology of pleural disease-
Chest X ray - Blinding of the costophrenie angle in small effusions More space is occupied by larger effusions- causing rib space widening on same side and mediaslinal shift to the other side.
USG - Helps in guided pleural tops and diagnosing loculated effusions.
CECT Chest - Helps in completed case infected pleura shows 'thickened pleura or split pleura sign' which refers to thickened enhancing parietal and uâ€¦â€¦.. pleura separated by pleural fluid.
Imaging of pleural disease: Clines in chest medicine 27 (2006)
Q.1 Which drugs can cause pleural effusions?
Ans. Nitrofurantion, dautrolene, ergot alkaloids, amiodarone, methotrexate, procarpazine, clozapine
and IL-2. The effusions are frequently cosmophilic.
Q.2 What are the common clinical and lab features of tubular pleural effusion?
Ans. The diagnosis of tubercular plevritis should be suspected in any patient with undiagnosed pl.
effusion following are the common features:
Clinical: subacute course of illness characterized by cough, fever and pleuritic chest pain.
Lab: Exudate with predominantly small lymphocytes. Protein level more than 3.5 g/dL usually higher. The diagnosis is established by showing a pleural fluid ADA level more than 4OIU/L in a lymphocytic pleural effusion.
Ref: 1. Light RW. Update on tuberculosis pleural effusion. Respirology 2012; 15:451-8.
2. Light RW. Pleural effusion, In. Musani AL, editor, pulmonary disease, Med clim N
Am 95 (2011) 1059.
Q.3 What are common sensitive & specific symptoms in childhood tuberculosis?
Ans. In developing countries, tuberculosis should be considered in almost all clinical settings. Highly suggestive sensitive symptoms are:
Persistent cough longer than 2 weeks (earlier it was 3 weeks)
Documented failure to thrive for 3 months.
The symptoms that are considered very specific are:
Q.4 Based on which diagnostic test treatment for tuberculosis should be started?
Ans. The diagnosis of tuberculosis can be challenging even with newer (latest) investigations. The timeless principles remain a high index of suspicion is essential, and when in doubt, particularly in high risk situations such as very young children, blind treatment is safer than a prolonged period of diagnostic hunting. In general, treatment legitimately can be started on clinical suspicion alone in young children. Otherwise not treating has its own horrific irreversible consequences like mâ€¦â€¦â€¦ and CNS tuberculosis.
Ref. Bush A. Recurrent respiratory infections. In Chang AB editor common respiratory symptoms and illnesses: A graded evidence based approach. Pediatrician N Am 56(2009): 93-4
Q.5. For what reasons is sputum a poor yield specimen for diagnosis of tuberculosis.
Q.6 Why is sputum positively for tubercle bacillus very low in children
Ans. For the following reasons childhood TB is often sputum negative -
Children with TB disease have a small bacterial load.
Children very rarely have cavitating disease. (Cavities house very high bacterial load otherwise).
Young children swallow rather than expectorate sputum.
Children are less able to generate the tussive forces needed to aerosolize bacilli.
Q. What can be done to inducer sputum in patient unable to expectorate?
Ans. Nebulizer with sterile hypertonic saline (3% to 6%).
Ref. Maher D, Raiglione M. Global epidemiology of tuberculosis. Clim chest Med 2005; 26(2). 167-82
Bush A, Recurrentâ€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦. P 146-147.
Q. What is the mode of transmission of tuberculosis?
Q. What is the mechanism?
Ans. Large respiratory droplets (secretions) come into environmental are due to coughing by an infections patient (open case of tuberculosis). These droplets the dry in the air by loss of moisture into small 1-5 um diameter particles. These dried residua of larger respiratory droplets are called droplet nuclei. The small particles remain suspended in air and when inhaled reached the peripheral lung alveoli easily. Their small size and negligible settling tendency prevents their trapping in the respiratory tract mucus.
Q. Where does the TB infection begin?
Ans. Alveolar macrophage, Mycobacterium TB has evolved mechanism to evade killing by the macrophages, which, ironically provide the essential intracellular environment for its initial growth.
Q. How many microbes are required to start an infection?
Ans. As little as single organisms can cause infection is a susceptible host.
Q. What are the host factors that influence establishment of TB infection and its progression to disease?
Ans. When the organism reaches the distal lung alveoli, bypassing the airway defenses it is taken up by macrophages and the infection is established. This result is acquiring the all indicated immunity and delayed type hypersensitivity to HTB, which to getter contain spread of infection within the host.
Once infected will HTB, the latent infection is lifelong. However, immune suppression and genetic sucephilibility are important host factors that underlie its progression to disease malnutrion, HIV infections diabetes are important risk factors.
Q. How is transmission of HTB different from other respiratory pathogen?
Ans. Most of the respiratory Bacteria and â€¦â€¦â€¦ spread through the coughed up secretions or large respiratory droplight. These are more than 100 um diameter particles that little within one meter of the coughing person. These first deposit in the upper airway, â€¦â€¦ and multiple and than by micro aspiration of a large dose of these secretions from upper air way to lung pneumonia happens.
This is in contrast to the HTB transmission in which 1 to 5 um to size droplet nuclei are easily inhaled to distal lung resulting in infection is alveolar macrophage.
Q. What is the risk associated with an untreated open case of tuberculosis?
Ans. Epidemiological data suggest than an infections case infects 6-10 susceptible hosts/year. Children are usually not infections or open cases. So when treating children, it is important to locate and treat the infection source case also.
Q. What are the common symptoms of pulmonary tuberculosis (disease) in children?
Ans. 1. Persistent cough >2 wks
2. Persistent fever
3. Weight loss or failure to thrive (FTT)
4. Night sweats severe though to require a change of clothes.
Difficulty in breathing
All these symptoms are episodic and are present when an acute exacerbation (attack) of asthma occurs. There may only be a past history of such symptoms.
HOPI: Cough- Onset associated and aggraded with viral infections/exercise/exposure to allergens/ environmental precipitants like pollens / dust/ animal fur/ smoke-cigarette/agarbatti /Chula smoke, exercise /emotional upset/ weather changes. The onset and duration (of cough symptoms). Any diurnal variation, whether cough is episodic or seasonal or perennial (throughout the year).
Relieving factors: Relived or improved by medication - what? Corticosteroid, bronchodilators, Nebulization.
Difficulty in breathing: Onset-acute /over few days; associated with cough / chest tightness/ wheezing; present at rest or with bouts of cough or activity / exercise; relieved by medication or nebulization.
Any H/O chest pain (Plevritis) or fever.
Present as episodic / seasonal or throughout the year.
Relieved or partially relieved after the acute episodic or persistently present.
Wheezing: Musical whistle live sound audible during acute episodic differentiate if from upper airway noisy breathing due to exercise secretions snoring and strider.
Chest tightness: Usually associated with breathlessness any H/O chest pain- then outset, duration and character of pain - local tenderness - muscular skeletal or increased with coughing/ rapid breathing-pleuritic pain.
Any H/O thick nasal discharge (sumunities)
H/O itching in nose (allergic rhinitis)
H/O Choking or swallowing problems sincerely infancy
H/O exacerbation with menstrual cycles
Any H/O fever/ severe chest pain/ foreign body inhalation/ unconsciousness/ abnormal body movements (for risk of operation).
Treatment history : Admitted to hospital â€¦â€¦â€¦. days back. Any improvement/deterioration in breathlessness and general condition since then Treatment given, Tablets/Syps. Nebulizations-how frequently given. Nature of illness told.
Whether this is first episode or there also have been previous episodes of breathlessness for this patient admitted first time or 2nd ,3rd time or frequent hospitalizations whether the patient is taking any chronic treatment for this condition. In what form-tablet, syrup, dry powder inhalation, inhaler with spacer or nebulization at home. Frequency and technique of inhaler therapy-right or not. Compliance with treatment - treatment taken only for duration of symptoms or later (prophylactic) also, as prescribed.
age of onset H/O similar episodes in past.
H/O nabulizations and hospital admission
H/O pneumonia etc. during neonatal period or infancy.
H/O asthma/ similar symptoms in an effected close relative in family.
H/O allergies / eczema in family.
Any pets in home
Any smoker in family.
Personal H: A sensitive exploration for H/O smoking in teenaged.
Diet H Routine
I/H: As per schedule, Any special vaccines received especially pneumococcal vaccine viral influenza and H influenza vaccine.
Physical examination usually the patient kept for examination has its respiratory difficulty settled so the patient may have minimal physical fin days on examination.
The observation part of examination is easy to do while taking the history. Without disturbing the child or giving him/her any extra attention - the respiratory rate and lose of breathing or labored breathing, if any, are noted Especially look for nebulizer, inhalers and oxygen port and tubing's nearby.
GPE Routine Pallor / Cyanosis / Icteres / rash / pedal edema + nasal discharge / any nasal polyps / clubbing
Respiratory system: RR
Normal easy / labored breathing Shape of chest - Normal or increased AP diameter with well developed pectoral muscles - Pectus carinatum or excavation may be seen description of chest retractions, if any, supraclaweular retraction, intercostal, subcortal, subexphoid retraction look for any asymmetrical chest movements
Palpation Percussion / of use only older child who can cooperate for examination
Auscultation: Air entry present all over chest or reduced in one side / one region carefully hear for prolonged expiration or musical expiratory sound - wheeze, all over the chest wheeze heard all over / local region-site-of chest.
Summary - Presenting complaints (Recurrent respiratory distress without fever)
Response to nebulization + on inhaler/ bronchodilator therapy
Wheeze on auscultation
Most likely diagnosis is asthma
Q. What is asthma? Asthma is most common chronic respiratory disease.
Ans. Asthma is characterized by children inflammation of airways that leads to widespread and variable airflow obstruction. The tried of symptoms of asthma is dyspnea, cough and wheezing; wheezing being the sine quanon.
The cough is typically nonproductive and episodic; consistent rhinitis or sâ€¦.. is very common and may contribute to cough. Wheezing and chest tightness is also episodic. The wheezing can occur in response to some environmental trigger or without it. Common triggers are cold air, exercise, emotional situations cat dander, pollen and fumes. Avoidance of the triggers can reduce symptoms, so it is important to know about patient's triggers.
Q. What specific lab test helps in diagnosis of asthma?
Ans. Spirometry , It is the gold standard. It reveals airflow obstruction defined by a reduced ratio of FEV,/FVC, with a disproportionate decrease in FEV, compared to FVC. There should be substantial improvement of at least 12%. In the FEV, after treatment with short acting bronchodilator; typically 4-8 puffs of salbutamol are used.
However, spirometry may be normal or nondiagnostic in a patient without any exacerbation or symptom or controlled state with asthma medications
Ref. Pascual RM, Peters SP Asthma. Musani AL editor. Pulmonary disease. Med clime N Am 2011; 95 (6). 1115-1117.
Q. What are different types of cough?
Ans. Cough type Disease
Staccatoâ€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦.. chlamydia in infants.
Paroxysmal + whoopâ€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦. pertussis; Parapertussis.
Barking cough - Group, tracheomalacia, Psychogenie.
Honking - Habit cough
Chronic wet cough in morning - lung absess , bronchiectosis
Ref: Chang A B, Cough, In AB chang, editor. Common respiratory symptom and illnesses: A graded evidence based approach, Pediatr
Clin N AM 2009; 56 (1) : 27
Chang AB, Glomb WB. Guidelines for evaluating chronic cough in pediatrics ACCP evidence - based clinical practice guidelines. Chest 2006; 129 : 260 S - 835
Q. What other conditions than asthma can cause wheezing in infants and toddlers? (Differential diagnosis)
Ans. Foreign body aspiration: Congenital abnormalities of heart great vessels and airways; recurrent aspiration pneumonia, celiary dyskimenia; Mediastinal mosses.
Ref. National asthma education and prevention program expert panel. Guidelines for diagnosis and management of asthma - update on selected topics. Bethesda, M D. U S department of health and human service. National heart, lung and blood institute; 2002 N/H publication No. 02-5075.
Q. Are inhaled or oral systemic steroids of any use in an infant with wheezing due to brancholities?
Ref. Garrison MM, Christakis DA, Horvey E, etal. Systemic corheosteroids in infant bronchiolitis a meta analysis Pediatrics 2000; 105 e44
Martinez FD, Weight AL, Tausig LM, etal Asthma and wheezing in first six years of life N Eng/J Med 1995, 332. 133-8.
Q. In a patient on corticosteroid & B against inhaler therapy, what treatment is recommended during acute exacerbation?
Short acting B agonist like salbutamol by nebulization or MDI (mutered dose inhaler) with spacer device.
Dose. 2.5 mg or 5 mg for children below 5 years of age.
Anti cholinergic agent-Ipratropicum bromide by nebulization as an effective adjunct to B agonist therapy by nebulization.
Short course glucocorticoid therapy: Hospitalized children who are in severe distress or require high flow oxygen to treat hypoxia are candidates of IV corticosteroid therapy. The NH/BI guidelines for acute severe asthma recommend.
IV methyl prednisolone 6 hrly for 48 hours (1mg / kg / dose)
taper it to prednisolone 1-2 mg / kg / day (max. 60 mg) 12 hrly till the peak expiratory flow rate PEFR is 70% of expected or patient's, personal best orally administered corticosteroids as effective as IV for children who can take orally.
Inhaled glucocorticoid treatment offers an additive effect to systemic steroid and bronchodilator therapy for children with severe wheezing and dyspnea, possibly by exerting a more direct and efficient action on airway inflammation.
Ref. Sano F, Cortez G K, Sole D, etal inhaled budesomide for treatment of acute wheezing and dyspnea in children upto 24 months old receiving IV hydrocortisone. J Allergy Clim Immunol 2000; 105; 699-703.
Killner JD, Ohlsson A, Godomski AM, etal, Bronchodilators for bronchiolitis Cochrane database of systemic 2000; 2.(D001266)
Quareshi F, Pestian J, Daivies P, etal Effect of nebulized ipratropium on the hospitalization rates of children with asthma. N Engl J Med 1998; 339; 1030-5.
Q. What are the common stimuli that precipitate bronchoconstruction in asthmatic patient?
Exposure to an allergen outdoor-pollen, indoors-house dust mite, pets, cockroaches
Inhaled irritants smoke from Cigarette/ Bidi / Hukka /Chulha/ Industrial smoke, Air pollution.
Respiratory tract infections common cold, others
Q. What is the mechanism of exercise induced asthma?
Ans. Cooling of the airway (tracheobronchial mucosa).
During exercise, individuals have fast and deep breathing. This causes movement of large volume of cool and dry air move in the respiratory system. Before entering lungs this air is warmed and humidified by the trachea & bronchi. This result is heat loss (=cooling ) and moisture loss (= drying) of tracheobronchial mucosa. This precipitates the bronchoconstruction in susceptible patients.
The pathogenesis of frequent exacerbation in asthmatics in winter months is believed to be similar.
Q. When should inhaled corticosteroids be used in asthmatic children?
Ans. Inhaled corticosteroids are added when treatment of asthma requires more than infrequent use of an inhaled B2 agonist.
Q. What is the mechanism of action of B2 agonists like salbutamol and methylxanthines like theophylline?
Salbutamol (B2 agonist-sympatho mimetic) increases intracellular cAMP by activating adenylate cyclase enzyme further intracellular reactions are mediated by this cAMP resulting in bronchial smooth muscle relaxation.
Methylxanthines like theophylline increase cAMP by inhibiting its degrading enzyme phosphodiesterase.
Q. What are the new drugs against asthma and what is their mechanism of action?
Zileuton: This is 5-lipoxygenase enzyme inhibitor. This cause decreased production of leukotrienes which are main mediators in acute asthma.
Montelukast: Zaferlukast : These are leukotriene D4 receptor antagonists.
Omalizumab: This is Anti-IgE antibody. This is given parent rally to bind circulating IgE antibody.
C/O Fast/rapid breathing
C/O Difficulty in breathing.
HOPI: It includes the details of presenting complaints in order to reach a diagnosis and know the severity of the condition.
Cough: Particularly dry or wet, Wet cough is suggestive of a important underlying cause especially infections. Also duration; timing of day (daytime/ nighttime only or more in night); aggravating and relieving factors (like relation to feeling/ cold air/ pollen/ dust/ change of weather) should also be enquired.
Fever: Details of fever should be noted and correlated to the respiratory symptoms.
Faster or rapid breathing: The history may or may not be given. This should be confirmed by IMNCI cut off values for respiratory rate. History of current onset, retractions should always be taken difficulty in breathing. This is present along with the above complaints. Severity of condition is assessed by the difficulty in feeding/unable to speak or cry and other criteria b, MNCI for sincere pneumonia/ illness.
H/O Chest pain (pleural effusion/ Empyema)
H/O Malaise/ headache/ loose motions (systemic symptoms in a severe infection illness)
H/O recurrent pneumonia/ difficulty in breathing/ chest lightness/ relief with nebulizations -consider asthma.
H/O Contact with tuberculosis - A family member/ neighbor or close contact taking or has recently taken or stopped treatment for T.B. (tuberculosis).
This history of contact may always not be forthcoming but is most important.
History can be related to DOTS - like given free medicine from government hospital every other morning was there expectoration of bloody or blood- tinged sputum were chest x rays done-what he/she was told and how long the treatment continued.
Treatment history: H/O treatment taken for the present symptoms and any improvement in symptoms.
H/O any hospitalization
H/O X ray taken.
What diagnosis was told for treatment or hospitalization?
What indication were given prescriptions/ wrappers/ medicines brought along with or
H/O any injections?
Patients may receive corticosteroids by quacks and present with improvement in cough but markedly fast and difficult breathing.
Past History: H/O previous such episodes, H/O previous hospitalizations particularly important in H/O fever (for suggestive of pneumonia) and H/O nebulizations (dramatic relif C nebulization of bronchodilators is suggestive of asthma). H/O seasonal exacerbations is suggestive of asthma H/O persistent sinusitis, short stature is suggestive of câ€¦â€¦â€¦. dyskmenia/cysti fibrosis -sore.
Family History: H/O smoking is family (risk for asthma and pneumonia in infection)
H/O Asthma in family.
H/O recurrent pneumonia in family member- immunodeficiency syndrome -sare .
H/O tuberculosis in family or close contact-very common and important.
Obstetric H: â€¦â€¦â€¦â€¦ in birth order, Any problems/ respiratory distress in newborn if yes tails of that problem.
Immunization H: Whether immunized as per schedule, BCG scar-present/about H Influenza and pneumococcal vaccines optional vaccines received or not.
Vitamin A â€¦â€¦ monthly prophylaxis received with vaccination or not.
Diet H: Taking adequate calories and protein or not.
Details or important in underweight malnourished children.
Dev H: Studies in classâ€¦â€¦â€¦â€¦â€¦.. (appropriate for age)
Comparable to children of same age group, plays with them or not. If â€¦. Then developmental details should be taken.
Recurrent aspiration pneumonia usually occurs in developmentally delayed child.
Examination: The observation part of the examination is easy to do while taking the history, without disturbing the child or giving him/her any attention- the respiratory distress, less of breathing and respiratory rate are noted. Particularly important is to observe the child's cough.
GPE: Pallor/wide wrest/ â€¦â€¦.. like head/Cyanosis /pedal edema/ w pathy/Ictreus/Anthropometry malnourished
Dâ€¦â€¦â€¦. Sitting/leaving forward/lying down â€¦â€¦up or flat/inbaling oxygen by hood / nosal progs /mask
(paraphrenilia) IV canula in site e.g. doâ€¦â€¦â€¦â€¦ hand nebulizer lying nearby
Inspection: In distress-sitting/rapid breathing/nasal floring/chest retraction-supraclavicular, sub costal, intercostals or not. [usually distressed child is not kept in exam]
Count RR.(respiratory. rate)
Look for nasal flaring
Any nasal polyps/nasal discharge
Chest wall shape-normal/developed pectoral muscle and increased AP diameter (S/O asthma)
Protruding chest / indrawen chest
Details of chest retraction- supraclavicular/ Intercostals/sub costal use of accessory muscles for breathing.
Details cough directly drairved dry/wet, barking/whooping/bouts of continuous cough any audible sounds like wheeze/ strider/ greening/ rattling (staccate) (due to loose recreation in upper airway)
Due to small chest and uncooperative children for detailed palpation, percussion and auscuttation, observation is the most important part of respiratory system examination in children.
Palpation: Position of trachea: Palpate in supra sternal notch with one finger. Trachea may be central or shifted to one side, close to one sternomostoid muscle than the other. This is suggestive of shift of inediastinum to one side.
Chest expansion visually observed side of chest moving less should be confirmed by palpation when possible.
Percussion: One should first know the normal percussion note by doing it on many chests.
The percussion should be done gently & symmetrically to on the chest. The corresponding right & left side should be sequentially assessed and compared.
Condition underlying the area of perusion
Pneumonia (consolidation of lung
Markedly (story) dull
Auscultation: By auscultation, particularly look for symmetry / asymmetry of air entry on both side. Note the side of reduced air entry.
Hear the breath sounds and characterize adventitious sounds (crepts/wheeze/ bronchial (tubular) or otherwise).
Summary: Presenting complaints (cough, fever, rapid breathing)
Any positive treatment /Past/Family history as discussed.
Suggestive positive finding on examination
(Febrile/ sick on oxygen/chest retraction/wet cough/decreased movements on one side + crepts)
Suggestive of pneumonia
Q. What nature of breath sounds are heard normally over chest?
Ans. In a normal person, breath sounds over chest are heard mainly during inspiration and the sound is smooth and soft. Such normal breath sounds are called vescular breath sounds.
Q. What kind of breath sounds are heard are over an area of lung consolidation as in labor pneumonia?
Ans. When the lung tissue in consolidated or filled with fluid, it conduits the breath sounds better than normal air filled lung. Thus the sound is loud and harsh. The expiratory sound is heard equally loud & long as the inspiratory breath sound.
Similar sounds can normally be heard by stethoscope on auscultation over trachea in suprasternal notch. Better transmission of sound consolidated lungs results in following auscultatory signs.
Whispering pectoriloquy whispered syllables are clearly heard over the consolidated area than the normal lung tissue.
Bronchophony- words spoken by the patient can be heard distinctly better over consolidated lung than the healthy lung.
Egophony: When the patient speaks 'A' and it is heard as 'E' over the consolidated lung, this altered transmission of sound is called ego phony.
Q.1. What is the important of cough?
Ans. Cough is a reflex action with some voluntary control. The forceful expansion of air helps expel secretions and trapped inhaled particles in the mucous of respiratory tract. It also protects against aspiration.
Q.2. What is the role of cough mixture or syrups in treating cough?
Ans. A cough is a natural response to an offending cause. It is always important to diagnosis the primary cause. Then the cause should be treated rather than cough, which is a natural response to the cause.
Ref. Q1,2: Wheeler k. cough. In. Filed DJ, Isaacs D, Stroobant J
Editors : Tutorials in pediatric differential diagnosis .2nd edition
USA-Elsevier; 2005. P 116-117.
Q.3. What are the causes and consequences of impaired cough?
Ans. Impaired cough is seen in patient with muscle weakness, CNS dysfunction, cerebral palsy, vocal cord dysfunction, kyphoscoloin or pain. There is increased risk of pulmonary infections.
Q.4. What advanced imaging modality is better to look at lung parenchyma - CT or HRI?
Ans. CT chest: CT is particularly useful in evaluating. Supportive lung complications and to differentiate these from Empyema
2. Recurrent pneumonia and concern for underlying lesion (anomaly, FB).
3. In immune compromised children when CXR ray are confusing (for fungal pneumonia etc.)
Q.5. What age specific cut off's for tachypnia by WHO?
Respiratory rate breath's spmiaâ€¦..
60 or more
2no to 12 no
50 or more
1 yr to 5 yr
40 or more
Based on severity of symptoms & signs WHO has graded pneumonia as
Pneumonia, sever pneumonia and very sever disease.
Q.6. What is the typical clinical picture of broncholitis?
Ans. 50% of cases are from 2no to 7 no of age. It is a sacral puenmostis.
VUTI (cough +wheezing)
Premature born infants and those with congenital heart disease have severe disease.
Q.8. What age a granuloma?
Ans. It is a microscopic aggregation of epithuloid (activated) macrophages, usually surrounded by a cellar of lymphocytes.
Q.9. What is the cellular process in the development of tubercular granuloma?
Ans. It can be divided into 3 steps
Development of a monocytic infiltrate
Aggregation, maturation and organization of mononuclear cells into a gronuloma
Further evolution into an epitheloid granuloma.
Q.10. What is the different between a tubercular granuloma and a foreign body granuloma?
Ans. Unlike the relatively inactive foreign body granulomas formed in response to insert particulate matter, tuberculosis hypersensitivity type granulomas are immunologically active structures with a continual level of mononuclear cell death and cell replacement by active recruitment.
Ref. Tuberculosis: A comprehension 8,9,10-P 99
Q.11. What epidemiological evidence favours a diagnosis of tuberculosis?
H/O contact with infection case
Positive Monteux test
Compatible clinical and radiological treatment response
Q.12. What x ray findings suggest 'active' tubercular disease?
Endobronchial spread patterns or HRCT
Above finding when seen without gross pulmonary anatomy distortions are suggestive of active pulmonary tuberculosis.
Q.13. What findings are suggestive of 'inactive' or past tubercular infection?
Pulmonary anatomical distortion
Linear and reticules opacities
Q.14. What kind of pulmonary tuberculosis munies asthma closely?
Ans. Endobronchial tuberculosis.
Q.15. How is pathogenesis of Endo bronchial tuberculosis different in children than in adults?
Ans. In adults, the Endo bronchial spread occurs when heavy load of bacteria originating from cavitory lesions enters & seeds the mucosa.
In children, the cavitory lesions are usually not there.
The caseous mediastinal and paratracheal nodes allow spread of bacteria to the mucosa in children.
Q.16. What are the symptom of endobronchial tuberculosis and how it is diagnosed?
Ans. The main respiratory symptoms are wet cough and wheezing.
The CXR (Chest X ray) may be normal.
It is diagnosed by CT chest that shows enlarged hilor paratracheal and peribronchial lymph nodes with central (caseous) necrosis; external compression of bronchi by enlarged nodes and large endobronchial masses (due to endobronchial inflammation ) may also be noted.
On bronchoscope mucosal ulcers granulation tissue airway compression poly paid masses and circumferential bronchostenosis may be noted.
Ref 16 : (1) William DJ, York EL, Nobert EJ, Sprocele BJ : Endo bronchial tuberculosis presenting asthma, Chest 1988; 93.836.838.
Q. What is the mechanism of noisy breathing in an otherwise well child?
Ans. Parents often bring infants and small children to OPD (Out patient Department) with the complaint of noisy breathing. This is usually when the infant or small child is not able to class excess secretions from upper airways. Usually the cause is an upper respiratory track infection (URTI) but asthma and cystic fibrosis patients may also have similar complaints due to increased secretion.
Such noise is often palpable; the character of noise is coarse and is irregular its timing the sound is heard equally in both inspiratory and expiratory phases of respiration.
Ref. Elaine carter noisy breathing, In field DJ, Isaocs D, Stroabant J editors, Tutorials in pediatric differential diagnosis 2nd edition. USA: Elsevier; 2005. P 112-113.
Q. What are the common causes of noisy breathing?
Ans. Different type of noises may be noted in a child with noisy breathing. These are
Shuffle seen in acute viral cold or allergic rhinitis.
Snore: Due to obstruction in oro-naso-pharyngeal airway. It is seen is acute tonsillitis or pharyugitis. It is a common chronic noise heard during sleep due to chrome ally enlarged tonsils solenoids.
Strider is usually an inspiratory noise sue to obstruction in extra thoracic airways. It is seen in acute viral croup and in larygomalacia.
Q. What treatment is recommended for bacterial pneumonia?
Ans. Antibiotics: Co- Amoxicillin clarulanic acid. It is significantly more effective than amoxicillin.
In school going children or otherwise macro ides alone or with coamoxy clav are used when mycoplasma /chlamydia infection is suspected Erythromycin, Azithromycin, clarethromycin all are equally effective.
In case of antibiotic resistance to coamoxcyclav / penicillin report and /or clinical failure, following information can be used.
Resistant pneumococcus: Use vancomycin
Resistant H. Influenzal: Use ceftriaxone
Resistant staphylocous aureus : Use vaneomycin.
These are the most common organism causing community acquired pneumonia. Resistant isolates of these are now common in community.
So, for resistant community acquired pneumonia (AP)
Vancomycin + Ceftriaxone therapy is recommended Antibiotics are given for about 10 days. Ref pg
Wheeze: It is a musical whistling sound heard in obstruction of intrathoracic airway. It is most commonly seen in asthma but is also noted in viral / atypical pneumonia and small foreign body operation.
Ref: Mc Cue S. Understanding the evidence diagnostic accuracy of physical findings Evidence based physical diagnosis.
Philadelphia: W.B. Saunders Company; 2001. P3-23.
Q. What are the classical features of bacterial pneumonia?
Ans. Bacterial pneumonia should be considered in children if fever is higher than 38 5 c and is accompanied by tachypnea and chest retractions.
Wheeze in young children preschool age and below less than (5 year age) suggests a viral cause whereas in older child it suggests mycoplasma pneumonia. Sticky eyes and dry repetitive cough in a neonate or infant are suggestive of Chlamydia pneumonia.
Ref. British thoracic society, British thoracic society guidelines for management of community acquired pneumonia in childhood. Thorax 2002; 57 (suppli): i1-24
Q. What organisms cause pneumonia in children of different age groups?
Ans. Neonates the bacteria acquired from mother's genital region like group B streptococcus, E. coli, Klibsiella and other Gram-negative aerobes.
Infants: Respiratory syneytial virus RSV- broncholities (viral pneumonic) and other viruses; S. pneumonic; H. influenza & M. tuberculosis Preschool age: S. pneumonia, H. influenza, M. tuberculosis
School age, Mycoplasma, ----------do--------
Oxygen: For hypoxia, that is, when sPo2 oxygen saturation is 92% or less.
If pulse oxinetry is not available any of these clinical signs could be used to guide oxygen therapy according IMNCI prog. Nasal flaring , grunting with every breath, inability to drink or feed, drowny, lethargic ( depressed mental state),severe lower chest wall in drawing, head nodding, respiratory rate> To/min.
Oxygen therapy is stopped when oxygen saturation remains stable >90% in room air for at least 15 min in a clinically stable child (1 MNC1 guidelines)
Ref. (i) Kabra S.K, lodha R, Pandey RM. Antibiotics for community acquired pneumonia in children Cochrane Database Syst Rev 2006;3.(D004874)
(ii) Low DE, Pichichero ME, Schaod UB optimizing antibacterial therapy for community acquired respiratory tract infection in children in an era of bacterial resistance. Clim Pediatric (Phila) 2004; 43(2):135.51
(iii) Chang CC, Cheng AC, Chang AB. Over the counter (OTC) medication to reduce cough as are adjunct to antibiotics for acute pneumonia in children and adults. Cochrane Database Syst Riv 2007; (4): CD 006088
Q. What are common bacteria causing hospital acquired pneumonia?
Ans. Staphylococcus aurous and gram negative bacteria like pseudomonas acinetobacter, E. coli, Citrobocter. These organisms are often multidrug resistant, so local guidelines are necessary for the appropriate selection of antibiotics.
Q. What is IMNCI? How effective it is?
Ans. IMNCI (Integrated management of neonatal and childhood Illnesses) is a program me by WHO. It intends to decrease mortality in neonates and under five age children. It is a very effective programme and about 81 countries have adopted the guidelines with following the guidelines there is 25% to 35% reduction in childhood pneumonia mortality. It recommends tachypnea as primary finding sign to diagnose pneumonia.
RR > / min in age 0-2 mo
RR>50/ min in age 2-12 mo
RR> 40/min in age 1yr to 5 yr.
Q. What is meant by recurrent pneumonia? What are the important causes?
Ans. More than one pneumonia in 1yr time period or more than 3 episodes of pneumonia in lifetime is recurrent pneumonia'. This can be either focal or interstitial
Causes of recurrent pneumonia focal type:
Chronic aspiration e.g. in developmental delay, mental retardation.
Congenital heart disease
Causes of recurrent interstitial pneumonia:
AIDS- Pneumocystis jiroveci pneumonia
Lymphoid interstitial pneumonities
Recurrent streptococcus pneumonia infection.
Ref. (1) Eslamy HK, Newman B. Pneumonia in normal and immunocompromised children: An overview and update in Metter FH, editor. Advances in Pediatric thoracic imaging. Radiol clin n Am 49 (2011) 905-6.
(2) Lodha R, Puranik M, Natchu UCM, etal: Recurrent pneumonia in children clinical profile and underlying causes. Acta Pediatric 2002; 91(11) : 1170-3.
Q. What is the primary mechanism of occurrence of pneumonia?
Ans. In community acquired pneumonia, the major routs of aspiration is micro aspiration from a preciously colonized or pharynx. However tuberculosis virus and legionella spread mainly by inhalation route.
Q. What are the major determinations for acquiring pneumonia?
Ans. 1.Virulence of the infecting organism and size of the inoculums
2. Host immune response
Many conditions that affect these are therefore important risk factors for pneumonia. These predispositions are defective cough, defective mucociliary clearance impaired immunity smoking alcohol and recent proton pump inhibitor use. Medical co morbidities such as congestive heart failure and chronic organ system disease of kindly, lives, lungs predispose to pneumonia.
Q. What is the believed mechanism of development of Acute Respiratory Distress Syndrome (ARDS) in pneumonia?
Ans. ARDS Immunological is acute lung injury that is widespread and in both the lungs. This is because of failure of immune response to localize to the rate of infection resulting in immune damage to both lungs.
Genetic variation of the immune responsiveness is believed to be behind this.
Q. What is the importance of chest X ray in diagnosis of pneumonia?
Ans. (1) Chest X rays are sensitive method for confirmation of pneumonia. These are routinely done in patients hospitalized for pneumonia for diagnosis and detection of completions.
2. Findings on CXR may include: consolidation, pleural effusion, necrotizing pneumonia, lung abscess, mullilobor involvement.
3. Patterns on CXR that provides diagnosed clues-
a- Peri bronchial distribution of bronchopneumonia -H. influenza
b- Labor consolidation- pneumocousis
c- Alveolar or interstitial pattern- atypical pathogens
d- Involvement of superior regiment of right lower lobe or posterior segment of right upper lobe - Aspiration pneumonia.
E- Bilateral nodular infiltrates - hematogenous dissemination.
F- Cavitations, bullas or necrotizing pneumonia - S. aureus, gram negative bacteria and anaerobes.
Q. What important organisms are causative of pneumonia in patients with influenza; in bioterrorism and in cruise ship/ hotel stay/ sauna bathe?
Suspected organisms' cause pneumonia
Recent influenza infection
S. pneumonia, S. aureus, H. influenza
Bacillus anthracis, Yersinia pestis Francisella tularensis
Cruise ship/ hotel stay/ sauna bath
Nair GB, Niederman MS. Community Acquired Pneumonia: An unfinished battle. In Musani AL editor. Pulmonary discuses
Med Clin N Am Nov 2011. 95 (6): 1143-116
Q. Name the respiratory illness associated with increase in air pollution?
Ans. Upper respiratory tract infections, bronchitis, cough, asthma and pneumonia.
Q. What are the effects of exposure to tobacco smoke on respiratory system?
Ans. Prenatal smoke exposure is associated with smaller conducting airway caliber and recurrent wheezing after birth. Infants and children exposed to smoke have increased cough, wheeze, respiratory infections and severity of asthma. The smoke exposure can be active or passive and has similar bad effects.
Ref. Redding GJ, Byrnes CA. Chronic respiratory symptom and diseases among indigenous children.
In : Chang AB, Sugleton R editors. Health issues in indigenous children : An evidence based approach for the general pediatrician. Pediatric clim N Am 56 (2009) 1325-1326.
2009; 56 : 1325-1326.
Ref: Stocks J, Dezateuse C. The effect of parental smoking on lung function and development during infancy. Respirology 2003; 8: 266-85.
Q What is the difference between immunogenic potential of Hib PRP-OMP and Hib PRP-T/ other conjugated vaccines?
Ans. Hib PRP OHP is more immunogenic. The poly Ribosityl Phosphate (PRP) Neisseria meningitidis outer Membrane protein (OMP) vaccine (PRP-OMP) gives significant immune response following the first dose at 2 mo of age, whereas the other conjugated vaccine require at least 2 doses to reach similar levels.
Ref. Menzies RI, Singleton R J. Vaccine preventable diseases and vaccination policy for Indigenous populations. In: Chang AB, Singleton RJ, editors. Pediatric Clin N Am 56(2009) 1264-1265.
Ref. Gatil K, Singleton R, Levine's OS, etal: Reemergence of invasive Homophiles influenza type B disease in a well- vaccinated population in remote Alaska. J Infect Dis 1999; 179: 101-6.
Q. What is the major difference between the 23 valets polysaccharide pneumococcal Conjugate vaccine (13 PCV)?
Ans. As with other polysaccharide vaccines, 23 VPPV is poorly immunogenic in children younger than 2 years and has no impact on mucosal carriage whereas the conjugate vaccine is highly immunogenic and effective against invasive pneumococcal disease in infants. Ref. Sam Pg. 1271.
Q. What are the grades of dyspnea.
Dyspnea only in severe exertion
Dyspnea walking upstairs
Dyspnea walking on level ground
Dyspnea at rest
Q. Name common causes for sudden severe dyspnea
Foreign body inhalation
Q. What are the common foreign bodies asperities and how it can be prevented?
Ans. Peanuts are the most common, Pieces of apple, carrot and hot dogs are also common. This can be prevented by avoiding these foods for children below 4 years of age.
Q. Common causes of blood in spulum?
Ans. 1. Pulmonary tuberculosis
2. Bacterial pneumonites
3. Bleeding diatheses as is leukemic.
Q. Anchovy souse sputum is seen in
Ans. Amebic liver absees penetrating into lung.
Q. Common predispositions to recurrent pneumonia /LRT/
Ans. 1. Foreign body
2. Ciliary dysfunction
Q. Features of sputum examination in asthma
Ans. 1. Charcot Leyden crystals (cosmophil derivatives)
2. Curschman's spirals (nucus costs of bronchioles)
3. Creola bodies (dumps of bronchiolar epithelium).
Q. What are the common causes of lung infiltrates and cosmophilia on blood examination?
Ans. 1. TPE Tropical pulmonary cosmophilia - floras
2. Loffler's syndrome- cosmophilia reaction to lung phase of helmet larval
3. Drug (hypersensitivity) nitrofurantion
Q. On lung function testing what are the important differences between obstructive and restrictive lung disease?
Ans. Obstructive Restrictive
^ RV RV,VC,TLC
FEV,/VC N, FEV,IVC
Q. What are the differentiating features of exudates/ transudate
Ans. Exudates Transudate
High protein Low protein
Low glucose (N) glucose
High LDH (N) /Low LDH
Due to exudative
Inflammation Due to osmotic gradient only
Q. What are the common causes?
Ans. Exudative pl. effusion Transudate
Para pneumonia Nephroins
Tumor (Primary/ Secondary Cirrhosis
Q. What are common causes of bilateral helar adenopathy
Fungal infections like histoplasmous
Q. What are the common causes of miliary nodules
Homonderosis due to severe mitral stenosis
Q. Common causes of cavity
Ans. Infection ( T.B., Klebsiella, anaerobes, fungi)
Q. Lobe of lung most commonly involved in aspiration pneumonitis
Ans. (R) Lower lobe supior segment
Q. Inhaled 3% Co2 is given to inhaled air for treatment of
Ans. Acute mountain sickness
Q. What measures can prevent AMS
Acelazolamids given 48 yr present
Sustained release Nefidipine 8 hrly during ascent
Q. What are the common antecedents of ARDS
Ans. Pneumonia - Infective
3. Multiple trauma