1DDX: October 20th,2006

Conditions of the respiratory system

Case study #1
3 ½ year old male child with gradual onset of stridor and cough.
Patient had a cold (rhinitis) one week ago
Child appears well (interacting well with mother and plays with toys in waiting room)
W/N (well nourished) and in NAD (no acute distress). Mother denies fever, drooling,
enuresis, diarrhea, anorexia or vomiting

Physical exam:
Height: 95cms
Weight 34lbs
BP: 104/63 mmHg (normal for 3 year old)
PR: 106 bpm
T: 36.8C
RR: 16rpm

HEENT (head ear eye nose throat) exam: no cervical adenopathy, no pharyngitis, no
tonsillitis.
Chest is clear to palpation and auscultation.
Progressive/gradual onset

This case was further discussed at end of respiratory section.

Congenital and developmental disorders:

CYSTIC ADENOMATOUS MALFORMATIONS

• “cystic” = fluid-filled
• “adenomatous” = mass of gland
• “Dys” = abnormal/inappropriate (pain)
• Idiopathic

BRONCHOGENESIS
“bronchogenesis” = synthesis of new bronchi, body attempting to make a lobe
• Can become infected. Discharge produced, normally yellow, but discharge takes the
colour of the lung. In smokers, it will be black.
• Lungs develop from pleuropotent cells. Each lung develops on its own.

PULMONARY HYPOPLASIA
1. Agenesis: (no genesis): other lung will compensate, tracheal deviation, increased
breathing rate.
2. Aplasia: Bronchus doesn’t split into bronchioles, etc. Lung doesn’t develop.
Bronchus but no lung.
3. Hypoplasia: Small and not functional. Better than 1 and 2.

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• Result of all 3: patient doesn’t breathe normally.
• In utero, pulmonary artery to aorta: ductus arteriosus.

Atelaectasis:
First breath that baby takes inflates the lungs. If lumen is blocked, lung collapses.

Compensation tachypnea: if function of lung is removed, breathing rate increases to

compensate for loss of lung.

EXTRALOBAR SEQUESTRATION
• Occurs outside pleura
• Not functioning lung (vascularly), but it is receiving air

INTRALOBAR SEQUESTRATION
• inside pleura

CYCTIC FIBROSIS

• Genetic
• Chronic cough
• FTT: failure to thrive
• Clubbing of fingers in child: is issue of heart or lung
• Mother almost always mentions salt crusts on baby’s skin (eccrine glands are
plugged)
• Salty Skin (know for exam), Mucoid Sputum (know for NPLEX): can’t dilute
sweat/sputum.
• Feculent vomiting = intestinal obstruction
• Steatorrhea (undigested food that floats), no pancreatic enzymes.
• Every duct in the body is affected.
• On chest x-ray, fuzzy = CF
• Viscous lung secretion in bronchi causes plugging, causes inflammation, causes
early death.
• Most common lethal genetic disease in Caucasians. Affects 1/2000.
• Patient can’t cough up sputum. Must drain or patient will die.
• Patient will invert themselves. Cough reflex goes away, because cough doesn’t
work to remove mucous.
• Difficult to see in child.
• Must be aggressive with treatment of infection because immune system doesn’t
function normally in lung.
• Defect in CF affects every organ. Glands cannot secrete.
• Life expectancy depends on extend of defect. Chromosome 7.
• Life expectancy can be 20 years less. Not death sentence.

DDX LECTURE 10, OCTOBER 20TH – PAGE 2

Treatments may include: mucolytics, good nutrition, drainage, treat every infection
aggressively, exercise lung every day.
LARYNGOTRACHEOBRONCHITIS (CROUP)
• Seal-like cough: fairly unmistakable.
• Video: humidity had no effect on croup: but parents, child relaxed. Seemed to
improve the croup through relaxation.
• Sounds like a seal barking, or a dog trying to clear throat.
• Unmistakable sound. (“stridor”)
• Anatomical malformation of subglottic tissue.
• Common: every child get some.
• Viral: no immunization against it. Caused by parainfluenza.
• Can get flu shot against influenza A+B: will this help?
• In this condition, you KNOW that the child is struggling to breathe in and out. Have
to know how far along the condition is: breathing like this for a few days is ok, but
longer might need hospitalization.
• Stenosis will make you more succeptible.
• Breast-fed children tend to have fewer viral infections.
• It is worse at night because they are in parasympathetic mode. Less
bronchodilation, harder to breathe.
• Worry... is it epiglottitis???

3 Ss of croup:
• Stridor (biphasic)
• Seal bark
• Subglottic swelling.

• Red flags** if you see these, it may have progressed to the next level: if the child
stops eating, drinking, laughing, if they are drooling, if they are turning blue, have
high fever.
• Without red flags, can treat with conservative measures naturopathically.
• For advice, call Telehealth Ontario (phone service), the Hospital for Sick Children:
they deal with croup all the time. If you are unsure, don’t take a chance.
• Most cases of croup move through and resolve, but hope for the best, expect the
worst.
• Most important DDx: ACUTE EPIGLOTTITIS!

• In X-ray of croup, you will see narrowing of trachea: called “steeple sign”.
Bottleneck.
• Usually lasts 5 days. In severe cases, the ones that involve respiratory distress,
need to administer drugs. They have gone into acute epiglottitis if they experience
respiratory distress.

ACUTE EPIGLOTTITIS

DDX LECTURE 10, OCTOBER 20TH – PAGE 3

• Can develop from progression of croup.
• Uncommon. Inflammation of SUPRAglottic tissue.
• Requires emergency intervention:
o IV hydration
o Intubation
o Antibiotics
• Bacterial cause (usually H. Influenza)
• There is a vaccine against this bacterium which reduces the risk of acute epiglottitis:
HIB vaccine
• Risk factors: see notes
• **will not be improved by steam**

Respiratory distress: see signs in notes.

DROOLING happens before respiratory distress. Drooling on its own is not cause for
concern as it could be caused by many factors, but look for other signs and look for
respiratory distress to follow.

In early stages, they look like they need help. Not happy kids.
In late stages, they look sleepy, drooling, have swollen tongue and mouth
Don’t want to eat/drink. If it is a young child, may try to drink, but it will go everywhere.
• Look for Thumb Sign on x-ray: epiglottis swells, goes downwards, looks like thumb.
Nothing is stopping growth.
• Resolved with tracheostomy
• Prognosis is very good if emergency procedures are followed. Recovery in 48-72
hours.
• If the underlying bacterial infection is not treated, or if the body doesn’t fight off the
infection, the bacteria can travel through the blood, pass the blood brain barrier, and
could potentially lead to meningitis.

• Main DDx: Croup.

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