Stridor, Viral Croup, Acute Epiglottis, Acute Wheeze, Bronchiolitis, Asthma, Pneumonia

2. • Stridor is a harsh, musicial sound due to partial
obstruction of the lower portion of the upper airway
including the upper trachea and the larynx.
Common causes
• Viral
laryngotracheobronchitis
Rare Causes
• Epiglottis
• Bacterial tracheitis
• Trauma to the throat
• Measles
• Diphtheria
• Hypocalcaemia
• Inhalation of smoke

3. • The severity of upper airways obstruction is best
assessed clinically by characteristics of the stridor (none,
only on crying, at rest, or biphasic) and the degree of
chest retraction
• Increased respiratory rate
• Increased heart rate
• agitation
Severe
obstruction
• Central cyanosis
• Drooling or reduced level
of consciousness
Complete
airway
obstruction
The degree of subcostal, intercostal, and sternal recession is a more useful
indicator of severity of upper airways obstruction than the respiratory rate.

4. • Viral croup accounts for over 95% of laryngotracheal
infections.
• Parainfluenza viruses are the most common cause,
but other viruses, such as rhinovirus, RSV and
influenza, can produce a similar clinical picture.
• Croup typically occurs from 6 months to 6 years of
age but the peak incidence is in the 2nd year of life.
• It is most common in the autumn.

5. > a barking cough, like a sea lion, due to tracheal edema and collapse
> hoarseness due to inflammation of the vocal cords
> harsh stridor
> the symptoms often start, and are worse, at night.
> variable degree of difficulty breathing with chest retraction
The typical features are coryza and fever followed by:

6. • When the upper airway obstruction is mild, the stridor and
chest recession disappear when the child is at rest and the
child can usually be managed at home.
• Inhalation of warm moist air is a traditional and widely
used therapy but it has not been shown to be beneficial.
• Oral dexamethasone, oral prednisolone, or nebulized
steroids (budesonide) reduce the severity and duration of
croup and are first-line therapy for croup causing chest
recession at rest. They have been shown to reduce the
need for hospitalization.

7. • In acute epiglottitis there is intense swelling of
the epiglottis and surrounding tissues
associated with septicaemia.
• It is caused by H. influenzae type b (Hib).
At presentation; at 16 hours, with nasotracheal
and nasogastric tubes and an
indwelling cannula
at 36 hours, following removal of
the nasotracheal and nasogastric
tubes.

8. • The onset of epiglottitis is usually very acute with:
high fever in a very ill, toxic-looking child
an intensely painful throat that prevents the child from speaking or swallowing
the child sitting immobile, upright, with an open mouth to optimize ariway
soft inspiratory stridor and rapidly increasing respiratory difficulty over hours
•In contrast to viral croup, cough is minimal or absent.
•Attempts to lie the child down or examine the throat with a spatula or
perform a lateral neck X-ray to identify a swollen epiglottis and
surrounding tissues must not be undertaken as they can precipitate
total airway obstruction and death.

10. • Acute wheeze is due to a partial obstruction of the
intrathoracic airways.
• This is from mucosal inflammation and swelling as
in bronchiolitis or bronchoconstriction as in asthma
or mechanical obstruction (e.g. with foreign body or
mucus).
• It may occur as a combination of all three.

11. • Bronchiolitis is the most common serious respiratory infection of
infancy: 2–3% of all infants are admitted to hospital with the disease
each year during annual winter epidemics; 90% are aged 1–9 months.
• RSV is the pathogen in 80%, the remainder are accounted for by
parainfluenza virus, rhinovirus, adenovirus, influenza virus, and
human metapneumovirus.

12. • Coryzal symptoms precede a dry cough and
increasing breathlessness.
• Feeding difficulty associated with increasing
dyspnoea is often the reason for admission to
hospital.

13. • Pulse oximetry should be performed on all children
with suspected bronchiolitis.
• No other investigations are routinely recommended. In
particular, chest X-ray or blood gases are only indicated if
respiratory failure is suspected.

14. • Asthma is the most common chronic respiratory
disorder in childhood.
• Worldwide, there has been a significant increase
in the incidence of asthma over the last 40 years,
although this has now plateaued in many high-
income countries.

15. • Diagnosing asthma in preschool children is often
difficult.
• Approximately half of all children wheeze at some
time during the first 3 years of life.
• In general,there are three patterns of wheezing:
viral episodic wheezing – wheeze only
in response to viral infections
multiple trigger wheeze – in response to
multiple triggers and which is more
likely to develop into asthma over time
asthma

16. • Asthma should be suspected in any child with wheezing on more than
one occasion, particularly if there are interval symptoms.
• It is best to describe the sound (e.g. ‘a whistling in the chest when your
child breaths out’) and ask if that fits with their child’s symptoms.
• Ideally, the presence of wheeze is confirmed on auscultation by a
health professional to distinguish it from transmitted upper respiratory
noises, which are often loud and easy to hear in children.
• Asthmatic wheeze is a polyphonic (multiple pitch) noise coming from
the airways. It is believed to represent many airways of different sizes
vibrating from abnormal narrowing.

17. Key features associated with a high probability of a
child having asthma include:
Symptoms worse at night and in the early morning
Symptoms that have nonviral triggers
Interval symptoms, i.e. symptoms between acute exacerbations
Personal or family history of an atopic disease
Positive response to asthma therapy.

18. Once suspected, the pattern or phenotype should be
further explored by asking:
How frequent are the symptoms?
What triggers the symptoms?
How often is sleep disturbed by asthma?
How severe are the interval symptoms between exacerbation?
How much school has been missed due to asthma

19. The depressions at the base of the thorax
associated with the muscular insertion of the
diaphragm are called Harrison’s sulci, and are
associated with chronic obstructive airways disease
such as asthma during childhood from chronic
increased work of breathing.
•Examination of the chest is usually normal between attacks.
•In long-standing asthma there may be hyperinflation of the chest,
generalized polyphonic expiratory wheeze with a prolonged expiratory phase.
•Onset of the disease in early childhood may result in Harrison’s sulci.
•Growth should be plotted but is usually normal unless the asthma is
extremely severe.
•The presence of a wet cough or sputum production, finger clubbing or poor
growth suggests a condition characterized by chronic infection such as cystic
fibrosis or bronchiectasis.

20. • If there is uncertainty in the diagnosis or disease
severity needs to be monitored, peak expiratory flow
rate (PEFR) may be measured or spirometry performed
• Peak flow is less sensitive to changes in airway calibre
than spirometry but is portable and therefore helpful
for serial measurements.
• Most children over 5 years of age can use a peak flow
meter or undertake spirometry.
• Spirometry involves measurement of forced expiratory
volume in 1 second blowing out as hard and as fast as
possible (FEV1).

23. • Mainly caused by Mycoplasma, Chlamydia or Adenoviruses
Atypical
Pneumonia
• Abrupt onset of cough followed by wheeze in previously well
child
• A chest X-ray performed during expiration will show persistent
hyperinflation of the lung distal to the obstruction.
Foreign Body
Inhalation
• suspect if acute urticaria, facial swelling, stridor, or previous
reaction to allergen.Anaphylaxis
Other causes of acute wheezing:

24. • Pneumonia peaks in infancy and old age, but is
relatively high in childhood.
• It is caused by a variety of viruses and bacteria,
although in over 50% of cases no causative
pathogen is identified.
• In clinical practice, it is difficult to distinguish
between viral and bacterial pneumonia.

25. Fever, cough and rapid breathing are the most common presenting symptoms.
lethargy, poor feeding, and an ‘unwell’ child.
Localized chest, abdominal, or neck pain is a feature of pleural irritation and suggests bacterial
infection.
The most sensitive clinical sign of pneumonia in children is increased espiratory rate
Maybe end-inspiratory coarse crackles over the affected area
Dullness on percussion
decreased breath sounds and bronchial breathing over the affected area are often absent in
young children.

26. A guide to the radiological
appearances of pneumonia in
different lobes of the lung. The
diagram shows the horizontal
fissures and shading illustrates
the key finding in each lobar
consolidation.
•A chest X-ray may confirm the
diagnosis but cannot reliably
differentiate between bacterial
and viral pneumonia
•In a small proportion of children
the pneumonia is associated
with a pleural effusion, where
there may be blunting of the
costophrenic angle on the chest
X-ray