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The Second Affiliated Hospital of Sun Yat-sen University

Tan Wei-ping

The Second Affiliated Hospital of Sun Yat-sen University

Tan Wei-ping

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Contents Upper Respiratory Infection Acute infectious Laryngitis Acute Bronchitis Bronchiolitis Pneumonia

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AnatomyAnatomy upper respiratory tract(URT)

• Cricoid Cartilage lower respiratory tract(LRT)

• URT ： Nose 、 pharynx 、 Uvula 、 Larynx 、 auditory tube 、 paranasal sinuses

• LRT ： Trachea 、 bronchia 、 bronchiole 、the respiratory bronchiole 、 the alveolar duct and the alveolus

upper respiratory tract(URT)

• Cricoid Cartilage lower respiratory tract(LRT)

• URT ： Nose 、 pharynx 、 Uvula 、 Larynx 、 auditory tube 、 paranasal sinuses

• LRT ： Trachea 、 bronchia 、 bronchiole 、the respiratory bronchiole 、 the alveolar duct and the alveolus

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Anatomy characteristics upper respiratory tract Nose: cilia↓, capillary↑ Sinuses: mucous

Auditory tube

tonsil

Larynx

Anatomy characteristics upper respiratory tract Nose: cilia↓, capillary↑ Sinuses: mucous

Auditory tube

tonsil

Larynx

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lower respiratory tract： Weak Cartilage Supporting , ciliary

function impairment

Right bronchus :straight , large

Collagen and elastin

fibers ， capillary ， interstitial tissue

Thorax ： chest wall, respiratory

muscle ； diaphragm ， mediastinum

lower respiratory tract： Weak Cartilage Supporting , ciliary

function impairment

Right bronchus :straight , large

Collagen and elastin

fibers ， capillary ， interstitial tissue

Thorax ： chest wall, respiratory

muscle ； diaphragm ， mediastinum

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Physiological characteristics The compensatory ability ↓

Respiratory rate↑

Pattern of respiration

Gas-exchanging membrane :diffuse rate

CO2 ＞ O2

Resistance of airway: child ＞ adult

Physiological characteristics The compensatory ability ↓

Respiratory rate↑

Pattern of respiration

Gas-exchanging membrane :diffuse rate

CO2 ＞ O2

Resistance of airway: child ＞ adult

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Arterial blood gas examination

(1) pH↓acidosis ；(2) PaO2↓ SaO2 ↓ hypoxemia ；

(3)PaCO2↑ carbon dioxide retention

mal-ventilation

Arterial blood gas examination

(1) pH↓acidosis ；(2) PaO2↓ SaO2 ↓ hypoxemia ；

(3)PaCO2↑ carbon dioxide retention

mal-ventilation

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The Immunological Characteristics：Impaired mucociliary clearance function

SIgA↓ 、 IgA↓ 、 IgG↓ subtype of IgG ↓

Alveolar macrophages ↓ , lysozyme ↓

lactoferrin ↓ 、 interferon ↓

complement ↓

The Immunological Characteristics：Impaired mucociliary clearance function

SIgA↓ 、 IgA↓ 、 IgG↓ subtype of IgG ↓

Alveolar macrophages ↓ , lysozyme ↓

lactoferrin ↓ 、 interferon ↓

complement ↓

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Upper Respiratory Infection (URI, or Common Cold)

Upper Respiratory Infection (URI, or Common Cold)

1. Etiology 90% viruses, the majority of colds.

rhinoviruses ,coronaviruses.

parainfluenza virus, adenovirus, enterovirus,

respiratory syncytial virus.

2. season fall and winter

3. Frequency three to eight colds a year.

1. Etiology 90% viruses, the majority of colds.

rhinoviruses ,coronaviruses.

parainfluenza virus, adenovirus, enterovirus,

respiratory syncytial virus.

2. season fall and winter

3. Frequency three to eight colds a year.

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Inoculation by virus

Invasion of epithelium ofRelease of nasopharynx,sinuses and URT cellular damageInflammatory of nasopharynxmediators in Cholinergicnasal secretions stimulation

Increased Increased vascular mucusPermeability production

bronchial constriction

Nasal Rhinorrhea postnasalStuffiness drip sore cough throat Pathophysiology of the common cold

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The clinical manifestation Common cold congestion a runny nose sneezing Cough,sore throat sometimes vomiting and diarrhea Fever,malaise,abdominal pain

The clinical manifestation Common cold congestion a runny nose sneezing Cough,sore throat sometimes vomiting and diarrhea Fever,malaise,abdominal pain

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Specific type of URI Herpangina:coxsackie-viruses group A.

summer /fall.High fever, sore throat ，

1-4mm vesicles /ulcers on anterior tonsillar

pillars, softpalate,uvula,tonsils pharyngeal wall.

Pharyngoconjunctival fever :type 3,7

adenovirus, spring /summer.

High fever, sore throat ， pharyngitis,

conjunctivitis, cervical lymphadenopathy.

Specific type of URI Herpangina:coxsackie-viruses group A.

summer /fall.High fever, sore throat ，

1-4mm vesicles /ulcers on anterior tonsillar

pillars, softpalate,uvula,tonsils pharyngeal wall.

Pharyngoconjunctival fever :type 3,7

adenovirus, spring /summer.

High fever, sore throat ， pharyngitis,

conjunctivitis, cervical lymphadenopathy.

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Complicationssinusitis

otitis media

cervical lymphadenopathy

Mesentery lymphadenopathyretropharngeal abscesspneumonia rheumatic fever acute glomerulonephritis

Complicationssinusitis

otitis media

cervical lymphadenopathy

Mesentery lymphadenopathyretropharngeal abscesspneumonia rheumatic fever acute glomerulonephritis

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Differential diagnosis

•Flu•Appendicitis•Early phase of acute

infectious disease

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Cold FluLow or no fever High fever

Sometimes headache Commonly headache

Stuffy, runny nose Sometimes stuffy nose

Sneezing Sometimes sneezing

Mild, hacking cough Cough, may progress

Slight aches and pains severe aches and pains

Mild fatigue Fatigue, may persist

Sore throat Sometimes sore throat

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Treatment increased fluid intakeavoidance of secondhand smokeSaline nose drops bulb syringe remove the mucuscool mist humidifierantipyretics, such as

acetaminophen,ibuprofen, decrease the discomfort of colds.

Do not give aspirin (associated with Reye syndrome)

Treatment increased fluid intakeavoidance of secondhand smokeSaline nose drops bulb syringe remove the mucuscool mist humidifierantipyretics, such as

acetaminophen,ibuprofen, decrease the discomfort of colds.

Do not give aspirin (associated with Reye syndrome)

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PreventionKeep your child away from a

person with a cold.Encourage your child to wash

his/her hands frequently and not to touch his/her mouth, eyes, or nose until their hands are washed.

Make sure toys and play areas are properly cleaned, especially if multiple children are playing together.

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Acute infectious LaryngitisAcute infectious Laryngitis

Etiology

• Virus or bacteria

• Typical anatomy

Etiology

• Virus or bacteria

• Typical anatomy

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Clinical manifestations

Barking cough, hoarseness, inspiratory

stridor, nasal flaring, suprasternal ,

infrasternal, intercostal retraction

Fever, dyspnea, cyanosis restlessness,

tachycardia . Worsen at night.

Congestion of pharynx, vocal cord edema

Clinical manifestations

Barking cough, hoarseness, inspiratory

stridor, nasal flaring, suprasternal ,

infrasternal, intercostal retraction

Fever, dyspnea, cyanosis restlessness,

tachycardia . Worsen at night.

Congestion of pharynx, vocal cord edema

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Grade of laryngic obstruction Ⅰ ： inspiratory stridor, respiratory difficulty only after activity Ⅱ ： symptoms occurs at rest. tachycardia, rhonchi Ⅲ ： Ⅱ + hypoxia, diminished breath sounds Ⅳ ： exhaustion, lethargy ， pallor , breath sounds diminish or disappear. dull of heart sounds, arrhythmia

Grade of laryngic obstruction Ⅰ ： inspiratory stridor, respiratory difficulty only after activity Ⅱ ： symptoms occurs at rest. tachycardia, rhonchi Ⅲ ： Ⅱ + hypoxia, diminished breath sounds Ⅳ ： exhaustion, lethargy ， pallor , breath sounds diminish or disappear. dull of heart sounds, arrhythmia

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Diagnosis & differential diagnosis laryngeal diphtheria laryngeal spasm bronchial foreign bodies

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treatment Maintaining of airway ： steam

inhalation, clearing of secretion.

antibiotics corticosteroid oxygen supply sedatives (phenergan) Ⅲ ↑ tracheotomy

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Acute Bronchitis(tracheobronchitis)Acute Bronchitis(tracheobronchitis)

Etiology

• Virus or bacteria

• Allergy, climate, air pollution, chronic infection of URT, particularly sinusitis.

• Rickets, malnutrition

Etiology

• Virus or bacteria

• Allergy, climate, air pollution, chronic infection of URT, particularly sinusitis.

• Rickets, malnutrition

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Clinical manifestations• unproductive cough 3~4days →

productive cough, purulent sputum → 5~10days

• Chest pain, shortness of breath

• Vomiting

• Physical finding: low-grade fever, roughening of breath sounds, rhonchi, coarse moist rales.

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Asthmatic bronchitis： ﹤3yrs old, eczema, allergy symptoms resemble asthma recurrent episodes reduced

after 3~4yrs old.

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Treatment

increased fluid intake

frequent shifts of position

antibiotics

cough suppressants

expectorants , antihistamines

acetaminophen

Treatment

increased fluid intake

frequent shifts of position

antibiotics

cough suppressants

expectorants , antihistamines

acetaminophen

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Bronchiolitis Etiology and epidemiology 50 ％ respiratory syncytial

virus(RSV) parainfluenza 3 virus,

mycoplasma, adenoviruses north——winter and early

spring Guangdong——spring ,summer

and early autumn

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2.PathophysiologyLesion: small air passages (diameter75 ～ 300um)Edema, accumulation of mucus and

cellular debris, spasm of smooth mussle→ ↑ resistance of small airway →expiratory difficulty →overinflation or atelectasis →hypoxemia, hypercapnia, acidosis

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Clinical manifestation

Infant 2yrs old, peak at 3~ 6 mo of ﹤age, male, non breast-feed

URI 3 ～ 4daysparoxysmal wheezy coughdyspnea develop rapidlymild or moderate fever

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Physical examinationR 60~80/minHR 160 ～ 200/minNasal flare, intercostal and subcostal

retractionsPallor, cyanosisHyperexpanded chest ， expiratory phase ↑

wheeze ， widespread fine crackles Liver and spleen palpable below the costal

marginCritical phase 48 ～ 72h afer onset of

dyspnea; recover during 5 ～ 15days

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Laboratory examination

WBC and differential cells count normal

Virus detected by antigen detection, PCR, or culture.

X-ray: hyperinflation of the lungs, emphysema, scattered areas of consolidation

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Differential diagnosis

AsthmaCystic fibrosisHeart failureForeign body in the tracheapertussis

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两侧肺纹理粗重。两肺中内带多数小斑片状及小结节病灶影。无病灶之肺部透过度增高。

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Treament Supportive treatment cool, humidified oxygen supply,

maintain SaO2 94%~96%; increased fluid intake ： oral

intake, intravenous solutions head and chest slightly elevated

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Ribavirin Antibiotics corticosteroids

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Pneumonia

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What’s PneumoniaWhat’s Pneumonia An abnormal inflammatory condition

of the lung infections (bacterial, viral or fungal) chemical injury (gastric acid/

aspiration of food/ hydrocarbon and lipoid pneumonia/ radiation induced pneumonia)

An abnormal inflammatory condition of the lung

infections (bacterial, viral or fungal) chemical injury (gastric acid/

aspiration of food/ hydrocarbon and lipoid pneumonia/ radiation induced pneumonia)

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Definition• Defined by clinical features or with the

addition of radiologic findings• Tachypnea: indicator of pneumonia(WHO) ＜ 2m, R≥60/min 2~12m, R≥50/min ＞ 12m, R≥40/min sensitivity of 74% and a specificity of 67%

compared with radiology

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Epidemiology• A leading killer of children≤5yr

1.9 million death worldwide/year

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Etiology

Viruses:40% ( ＜ 2yr)

Bacteria:27~44%– Streptococcus pneumoniae

– Staphylococcus aureus, Moraxhella catarrhalis,

– group A Streptococci, and Haemophilus

MP, CP:9~14%Mixed:23%

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Contributing Etiology: risk foctors

Malnutrition Rickets Iron-deficiency Immuno-deficency Congenital heart disease Low born bodyweight

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Clinical manifestation

fever

cough

Dyspnea(Tachypnea,cyanosis)

Localized crackles(fine moist rales)

Abnormal chest x-ray

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Classification Pathologic (anatomic changes)

lobar pneumonia: involves a single lobe

Bronchial pneumonia: patches around the tubes

Interstitial pneumonia: areas between the alveoli

Pathogenic (microorganisms )

bacteria

viruses

fungi

parasites

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Classification course of disease

– Acute

– subacute

– chronic

State of disease

– common

– severe

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Classification

Clinical manifestation– Typical

– atipical

The combined clinical classification

– community-acquired pneumonia(CAP)

– hospital-acquired pneumonia (HAP)

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BronchopneumoniaBronchopneumonia

1.Etiology viruses, bacteria, MP, CP.

2~3yrs old

2.pathology edema,infiltration

1.Etiology viruses, bacteria, MP, CP.

2~3yrs old

2.pathology edema,infiltration

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3 pathophysiologyhypoxemia, hypercapnia, toxemia

respiratory insufficiency

acidosis

myocarditis, heart failure, shock, DIC

toxic encephalopathy

toxic intestinal paralysis

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4.Clinical manifestation

(1) mild (commone)pneumonia ： fever

cough

dyspnea ( tachypnea, cyanosis)

crackles

Chest x-ray

4.Clinical manifestation

(1) mild (commone)pneumonia ： fever

cough

dyspnea ( tachypnea, cyanosis)

crackles

Chest x-ray

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两肺纹理增粗。两肺中下野中内带见斑片状阴影，密度较均匀。部分病灶融合成范围稍大的片状影

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(2) Severe pneumonia ：

other systems involved

myocarditis

heart failure

toxic encephalopathy

toxic intestinal paralysis

(2) Severe pneumonia ：

other systems involved

myocarditis

heart failure

toxic encephalopathy

toxic intestinal paralysis

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Heart failure① R ＞ 60/min② HR ＞ 180/min③ Sudden onset of restlesseness,Pallor,

cyanosis, delayed capillary refill( ＞3~5s)

④ Dull heart sound, gallop rhythm, Jugular vein congestion

⑤ Liver enlarged rapidly⑥ Oliguria or anuria, edema

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5.Complications

• Empyema

• Pyopneumothorax

• pneumatocele

5.Complications

• Empyema

• Pyopneumothorax

• pneumatocele

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6.Laboratory findings:

WBC, NBT,CRP

Pathogen(antigen and/or antibody)

chest x-ray

6.Laboratory findings:

WBC, NBT,CRP

Pathogen(antigen and/or antibody)

chest x-ray

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7.diagnosis

Fever, cough, tachypnea, dyspnea, localized

fine moist rales, chest x-ray

8.differential diagnosis acute bronchitis

tuberculosis

foreign bodies of trachea

7.diagnosis

Fever, cough, tachypnea, dyspnea, localized

fine moist rales, chest x-ray

8.differential diagnosis acute bronchitis

tuberculosis

foreign bodies of trachea

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男 2 岁半。 4 个月前吃蚕豆后发生呛咳，经常发烧，左侧呼吸音低。胸片：左侧阻塞性肺气肿。心 影稍右移，经支气管检查于左支气管取出蚕豆碎块。

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9. treament

(1) general therapy

(2) antipathogen therapy

antibiotics

antivirus

9. treament

(1) general therapy

(2) antipathogen therapy

antibiotics

antivirus

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(3)symptomatic therapy

oxygen supply

airway management

abdominal distention

fever

(4) Corticosteroid

(5) complications /underling disease

(6)Immunotherapy

(3)symptomatic therapy

oxygen supply

airway management

abdominal distention

fever

(4) Corticosteroid

(5) complications /underling disease

(6)Immunotherapy

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Characteristics of pneumonia caused by different pathogen

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1.respiratory syncytial virus pneumonia

age: 2~7mon fever:mild or moderate main signs: acute onset, wheeze,

expiratory difficulty, palpable liver and spleen.

Pallor, cyanosis, restlesseness Auscultation: diffuse rhonchi, fine

rales Chest X-ray:peribronchial thickening

or interstitial pneumonia

1.respiratory syncytial virus pneumonia

age: 2~7mon fever:mild or moderate main signs: acute onset, wheeze,

expiratory difficulty, palpable liver and spleen.

Pallor, cyanosis, restlesseness Auscultation: diffuse rhonchi, fine

rales Chest X-ray:peribronchial thickening

or interstitial pneumonia

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2.Adenovirus pneumonia

Age: 6mon-2yrs

main signs: acute onset, long duration

of high fever ， 7~ 10days or 2~3weeks

then pelter

Systemic toxic symptoms are obvious

Frequent cough ， paroxysmal wheeze,

dyspnea, cyanosis

2.Adenovirus pneumonia

Age: 6mon-2yrs

main signs: acute onset, long duration

of high fever ， 7~ 10days or 2~3weeks

then pelter

Systemic toxic symptoms are obvious

Frequent cough ， paroxysmal wheeze,

dyspnea, cyanosis

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late appearance of rales(3~7days)

myocarditis, heart failure, and

encephalopathy

X-ray changes early

late appearance of rales(3~7days)

myocarditis, heart failure, and

encephalopathy

X-ray changes early

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右肺中上野散在小灶状浸润阴影。左肺野中外带见大片状融合状阴影。其余肺野含气量增高。

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3.Staphylococcal aureus pneumonia ＜ 1 year are most commonly affected

Acute onset, severe systemic symtoms

High fever, respiratory distress, GI .

Physical examinations: early appearance of rales

Effusion, empyema, pyopneumothorax , abscess of other organs ， Sepsis

WBC↑, polymorphonuclear cells ↑

chest x-ray:infiltration, multiple abscesses

3.Staphylococcal aureus pneumonia ＜ 1 year are most commonly affected

Acute onset, severe systemic symtoms

High fever, respiratory distress, GI .

Physical examinations: early appearance of rales

Effusion, empyema, pyopneumothorax , abscess of other organs ， Sepsis

WBC↑, polymorphonuclear cells ↑

chest x-ray:infiltration, multiple abscesses

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4. Gram-negative bacillary pneumonia, GNBP

Haemophilus influenza , pneumonia bacilli

severe, hard to treament, poor prognosis

Systemic toxic symptoms , shock

Rales, Infiltration, consolidation, hemorrhagic necrosis

X-ray: lobar, or segmental, effusion, abscess

DIC

4. Gram-negative bacillary pneumonia, GNBP

Haemophilus influenza , pneumonia bacilli

severe, hard to treament, poor prognosis

Systemic toxic symptoms , shock

Rales, Infiltration, consolidation, hemorrhagic necrosis

X-ray: lobar, or segmental, effusion, abscess

DIC

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5. Mycoplasma pneumonia Usually over 5yrs, also infant sore throat, headache, myalgia Mild or moderate fever, 1~3weeks Unproductive cough, wheeze in infant Multiple system damage Auscultation: scattered rhonchi or rales. X-ray: “walking pneumonia”, effusions

5. Mycoplasma pneumonia Usually over 5yrs, also infant sore throat, headache, myalgia Mild or moderate fever, 1~3weeks Unproductive cough, wheeze in infant Multiple system damage Auscultation: scattered rhonchi or rales. X-ray: “walking pneumonia”, effusions

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6. Chlamydial pneumonia (c.Trachomatis)

age: 2~12weeks

Chronic onset, nasal stuffiness, cough,

tachypnea, rales, few wheezes

no fever

Eye sticky

6. Chlamydial pneumonia (c.Trachomatis)

age: 2~12weeks

Chronic onset, nasal stuffiness, cough,

tachypnea, rales, few wheezes

no fever

Eye sticky

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