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Diseases Of Respiratory Tract

  1. Choanal Atresia - M/C congenital anomaly of the nose Q.
It consists of a unilateral or bilateral bony (90%) or membranous (10%) septum between the nose and the pharynx; most cases are a combination ot bony and membranous atresia. Nearly 50% of the affected infants have other congenital anomalies

Diagnosis: Inability to pass a firm catheter through each nostril 3-4 cm into the nasopharynx.
The atretic plate may be seen directly with fiberoptic rhinoscopy. The anatomy is best evaluated by using high-resolution CT.

Treatment: Operative correction.
Choanal atresia: is associated with Charge Syndrome

- Charge SyndromeQ

  1. Coloboma
  2. Heart disease
  3. Atresia choanae
  4. Retarded growth and development or CNS anomalies
  5. Genital anomalies / hypogonadism
  6. Ear anomalies / deafness

Most patients with CHARGE syndrome have mutations in the CHD7 gene, which is involved in chromatin organization.


  1. Laryngomalacia is the most common congenital laryngeal anomaly.
  2. It is the most common cause of stridor in infants and children.
  3. Symptoms appear in first 2 weeks of life and increase in severity for upto 6 months.
  4. Typical presentation is inspiratory stridor which is exacerbated by any exertion (crying, agitation, feeding), supine position, and viral infection of URT.
  5. Stridor is due to partial collapse of a flaccid supraglottic airway during inspiration.

Acquired disorders of the nose.

  1. Unilateral nasal discharge and obstruction suggest the presence of a foreign body
  2. Epistaxis
    - Trauma including picking the nose and foreign bodies is the most common cause
    - Others- Adenoid hypertrophy
    Allergic rhinitis
  1. Common Cold

TABLE : Pathogens Associated with the Common Cold





Relative Frequency*

Agents primarily associated

With colds

Rhinoviruses Q




Agents primarily associated

With other clinical

Syndromes that also cause


Respiratory syncytial viruses


Influenaza viruses

Parianfluenza viruses



Boca virus



*Relative frequency of colds caused by the agent.


Conditions that can Mimic the common cold

Condition differentiating features
Allergic rhinitis Prominent itching and sneezing
Nasal eosinophils
Foreign body Unilateralm foul-smelling secretion
Bloody nasal secretions
Sinusitis Presence of fever , headache or facial pain ,or periorbital edema or persistence of rhinorrhea or cough for >14 days
Streptococcosis Nasal discharge that excoriates the names
Pertussis Onset of persistent or severe cough
Congenital syphilis Persistent rhinorrhea with onset in the 1st 3 mo of life.



  1. Otitis media is seen in up to 25% of small infants
  2. Mastoiditis, peritonsillar cellulites, sinusitis       
  3. Exacerbation of asthma. 
  1. Chronic Rhinitis: 

Chronic nasal discharge may be seen in

  1. Nasal polyp
  2. Chronic sinusitis
  3. Chronically infected adenoids      
  4. Cystic fibrosis
  5. Dysmotility cilia syndrome  
  6. Allergy                  
  7. Foreign body
  1. Retropharyngeal abscess 




Cause: Suppuration of retropharyngeal lymph nodes due to infection at its drainage sites:

  1. Adenoids
  2. Nasopharynx
  3. Posterior nasal sinuses or nasal cavity


  1. Dysphagia
  2. Fever
  3. Difficulty in breathing with stridor or croupy cough Q
  4. Torticollis
  5. Bulge in the posterior pharyngeal wall 


  1. I & D without general anesthesia
  2. Antibiotics
  3. Tracheostomy: If large causing mechanical obstruction to the airway 




  1. T.B. of the cervical spine
  2. T.B. of the retropharyngeal lymph nodes
  3. Secondary to tuberculosis of the deep cervical lymph nodes 


  1. Discomfort in the throat                             
  2. Pain                                                     
  3. Fever                                                
  4. Progressive neurological signs and symptoms due to spinal cord compression
  5. Neck may show tubercular lymph nodes 


  1. Retropharyngeal bulge
  2. Bone destruction
  3. Loss normal curvature of the spine 



External drainage:

  1. Drainage through cervical incision
  2. High abscess
    a.  Vertical incision along the posterior border of sternocleidomastoid
  3. Low abscess:
    a. Vertical incision along the anterior border of sternocleidomastoid 
  1. Parapharyngeal Abscess:
  • Etiology: Pharynx: Tonsillitis. Adenoiditis, Peritonsillar abscess
                   Teeth: Dental infections
                   Ear: Petrositis & Bezold’s
                   Infection from the communicating spaces
    External trauma: Penetrating  injuries of the neck 

Clinical symptoms & signs:

  1. Anterior Compartment:
    1. Prolapse of the tonsil and tonsillar fossa
    2. Trismus
    3. External swelling behind the angle of the jaw
    4. Marked odynophagia 
  2. Posterior Compartment:
    1. Bulge in pharyngeal wall posterior to the posterior pillar
    2. IX. X, XI, XII palsy
    3. Sympathetic chain involvement
    4. Parotid bulge
    5. Minimal trismus 



Abscess drainage: Through a collar incision in the neck at the level of Hyoid-bone, IV antibiotics



  1. Laryngeal odema
  2. Spread to retropharyngeal space
  3. Jugular vein thrombophlebitis
  4. Spread to the mediastinum along the carotid space
  5. Erosion of the carotid artery 
  1. Obstructive sleep apnea and hypoventilation in children:
    1. A combination of prolonged partial upper airway obstruction and intermittent complete obstruction that disrupts normal ventilations.
    2. Polysomnography, an overnight recording of multiple physiologic sensors during sleep is the “Gold Standard” for the diagnosis of OSA.
  2. Cystic adenomatoid malformation: 
    1. Second most common congenital lung lesions after lobar emphysema
    2. Polyhydramnios common (50%) 
  3. Laryngotracheobronchitis (Croup)
    1. Primarily by viruses.
    2. Parainfluenza-virus is responsible for approx. 75% of cases.
    3. Mild brassy cough with intermittent inspiratory stridor and as obstruction increases stridor becomes continuous and respiratory distress. 


  1. Humidification
  2. Humidified oxygen
  3. Adequate hydration
  4. Nebulized Adranaline
  5. I/V Dexamethasone
  1. Acute epiglottitis
    1. Most commonly due to H. influenzae type b Q.
    2. High fever, sore throat, rapidly progressive respiratory obstruction.
      Epiglottitis appears angry red, and swollen.
    3. X-ray lateral neck shows thumb sign
    4. T/t : Amoxicillin 
  1. Acute bronchiolitis
    1. predominantly a viral disease.
    2. Respiratory syncytial virus (RSV) is responsible for >50% of cases
    3. Other agents include parainfluenza , adenovirus, Mycoplasma, and, occasionally, other viruses.
    4. Human metapneumovirus is an important primary cause of viral respiratory infection or it can occur as a co-infection with RSV.
    5. There is no evidence of a bacterial cause for bronchiolitis
    6. Bronchiolitis is more common in males, in those who have not been breast-fed, and in those who live in crowded conditions.
    7. RSV infection incites a complex immune response
    8. Hypoxemia is a consequence of ventilation-perfusion mismatch early in the course. With severe obstructive disease and tiring of respiratory effort, hypercapnia may develop.
    9. The physical examination is characterized most prominently by wheezing., nasal flaring and retractions.
    10. Auscultation may reveal fine crackles or overt wheezes, with prolongation of the expiratory phase of breathing.
    11. Hyperinflation of the lungs may permit palpation of the liver and spleen.
    12. chest radiography reveals hyperinflated lungs with patchy atelectasis.

Severity of acute laryngotracheobronchitis





General appearance

Happy, feeds well, interested in surrounding

Irritable but can be comforted by parents

Restless or agitated or altered sensorium


Stridor on coughing, No stridor at rest

Stridor at rest and get worse when agitated

Stridor at rest and worsens on agitation

Respiratory distress

No distress

Tachypnea and chest retractions

Marked tachypnea with chest retractions

Oxygen saturation

>92% in room air

>92% in room air

>92% in room air, may be cyanosed



  1. Response to bronchodilators is unpredictable
  2. The use of ipratropium bromide in this population is controversial
  3. A trial of inhaled steroids may be warranted in a patient who has history of atopy including food allergy or eczema.
  4. The mainstay of treatment is supportive.
  5. If hypoxemic, the child should receive cool humidified oxygen.
  6. Sedatives are to be avoided because they may depress respiratory drive.
  7. Oxygen is indicated in all infants with hypoxia.
  8. Nebulized epinephrine may be more effective than β-agonists.
  9. Ribavirin, an antiviral agent administered by aerosol, has been used for infants with congenital heart disease or chronic lung disease.
  10. Antibiotics have no value unless there is secondary bacterial pneumonia. Likewise, there is no support for RSV immunoglobulin administration during acute episodes of RSV bronchiolitis. 


  1. There is a higher incidence of wheezing and asthma in children with a history of bronchiolitis unexplained by family history or other atopic syndromes.
  2. Approximately 60% of infants who wheeze will stop wheezing. 


  1. Reduction in the severity and incidence of acute bronchiolitis due to RSV is possible
  2. RSV intravenous immunoglobulin (RSV-IVIG, RespiGam) and palivizumab (Synagis),
  3. Palivizumab is recommended for infants <2 yr of age with chronic lung disease (bronchopulmonary dysplasia) or prematurity. Meticulous handwashing is the best measure to prevent nosocomial transmission.
  1. Eosinophilic Lung Disease (Loeffler Syndrome)
Transitory pulmonary infiltrations which very in size, may resemble miliary tuberculosis and blood eosinophils as high as 70%
  1. Toxocara canisQ
  2. Ascaris lumbricoidesQ
  1. Bronchiolitis Obliterans

Bronchiolitis obliterans (BO) is a rare, chronic lung disease of the bronchioles and smaller airways. BO most commonly occurs in the pediatric population after respiratory infections (adenovirus, Mycoplasma, measles legionella, influenza, pertussis). Other causes include inflammatory diseases (juvenile rheumatoid arthritis, systemic lupus erythematosus, scleroderma, Stevens-Johnson syndrome), toxin fume inhalation.


Pathogenesis. After the initial insult, inflammation affecting terminal bronchioles, respiratory bronchioles, and alveolar ducts may result in the obliteration of the airway lumen. Epithelial damage resulting in abnormal repair is characteristic of BO. Complete or partial obstruction of the airway lumen may result in air trapping or atelectasis.



  1. Oxygen
  2. Ribavirin in some cases
  3. Salbutamol
  4. CPAP in sever cases 
  1. Pneumonia

Consolidation of alveoli or infiltration of the interstitial tissue with inflammatory cells.


Atypical pneumonia syndrome atypical in true of extrapulmonary manifestations low grade fever patchy diffuse infiltrates SARS severe acute respiratory syndrome


TABLE : Etiologic Agents Grouped by Age of the patient


Age Group

Frequent Pathogents (In Order Of Frequency )

Neonates (< 1) mo

Group B streptococcus Escherichia call other gram negative bacilli, Streptococcus

Pneumoniae Haemophilus influenzae (type b, “nontypable)

1-3 mo Febrile pneumonal

Respiratory syncytial virus other respiratory viruses (parainfluenza viruses Influenza virus adenoviruses ) S. pneumoniae, H influenzae (type b, *nontypable)

Afebrile Pneumonia

Chlamydia trachomatis Mycoplasmas mo hominis ureaplasma urealyticum cytomegalovirus

3-12 mo

Respiratory syncytial virus other respiratory viruses (parainfluenza virus, influenza

Virus, adenoviruses ) S. pneumoniae H. influenzae( type b* nontypable).

c. trachomatis , Mycoplasma pneumoniae group A Streptococcus

2-5 yr

Respiratory viruses (parainfluenza viruses influenza viruses adenoviruses),

S. pneumoniae H. influenzae (type b, *  nontypable ) M pneumoniae

Chlamydophilia pneumoniae s, aureus, group   A Streptococcus

5-18 yr

M. pneumoniae s. pneumoniae c. pneumoniae H. influenzae (type B*  nontypable

influenza virus adenoviruses other respiratory viruses


≥ 18 yr

M. pneumoniae ,S. pneumoniae C. pneumoniae H, influenzae (type b* nontypable ),influenza viruses adenoviruses Legionella pneumophila


Recurrent pneumonia is defined as 2 or more episodes in a single yr or 3 or more episodes ever, with radiographic clearing between occurrences.


Slowly resolving pneumonia refers to the persistence of symptoms or radiographic abnormalities beyond the expected time course.


Special diagnostic features:

  1. Pneumococcal pneumonia: (Streptococcus pneumoniae)
    1. Lobular or lobar pneumonia
    2. Less common in the infants under 1 year of age.
    3. Cough is initially dry but may be associated with thick rusty sputum. 
  2. Staphylococcal pneumonia
    1. % of the patients are below the age of one year.
    2. It may be complication of measles, influenza and cystic fibrosis.
    3. The pneumonic process is diffuse initially
      1. Multiple microabscesses
      2. Pneumatocele*** - pathognomonic of staphylococcus
      3. Staphylococcal abscesses in the lungs may erode into the pericardium causing purulent pericarditis and pleural cavity -   emphysema 

Emphysema in a child below 2 years of age is nearly always Staphylococcal in etiology****

H. Influenzae: -3 months to 3 yearsQ.

Streptococcal Pneumonia                                                                

  • By Group A beta hemolytic streptococci is usually secondary to measles, chickenpox, influenza or whooping cough.
  • Lymph nodes are enlarged.

Primary atypical pneumonia

  1. Mycoplasma pneumoniae
  2. Involves the interstitial tissue of the lungs in which round cell infiltration is seen.
  3. X-ray findings are more extensive than suggested by physical findingsQ.
  4. Poorly defined ha2y or fluffy exudates radiate from the hilar regions.
  5. Enlargement of lymph nodes*** and pleural effusion
  6. T/T-Macrolides group (erythromycin) and tetracycline 

Viral pneumonia


Respiratory syncytial virus is the most important cause in infant-; under 2 year of age.


Acute Respiratory Tract Infection (ARTI) Control Programme:


The common bacteria causing LRTI in preschool children include


- H. influenzaeQ


- S. pneumoniaeQ


- StaphylococciQ

  1. Rapid respiration is defined as respiratory rate of more than 60,50 or 40/min in children below 2 months, 2 months - I year and 1-5 years respectivelyQ.
  2. Difficulty in respiration - lower chest in drawing


  1. If (he child has fast breathing but there is no chest in drawing - pneumonia - manageable at home with oral cotrimoxazole for a period of 5 days.
  2. If the child has chest in drawing - severe pneumonia
  3. Presence of cyanosis or severe chest in drawing or other danger sign - very severe pneumonia 
  1. Bronchial Asthma 

It is characterized by recurrent episodes of dyspnoea Q, dry cough Q, and wheeze Q caused by reversible airways Q obstruction.

Three factors contribute to airway narrowing:

  1. Bronchial muscle contraction Q: Triggered by a variety of stimuli;
  2. Mucosal swelling Q
  3. Mucosal inflammation Q, caused by mast cell and basophil degranulation resulting in the release of inflammatory mediators; increased mucus production. 


  1. Cold air, exercise, emotion, allergens (house dust mite, pollen, animal fur), infection, drugs (eg aspirin, NSAIDs, blockers).
  2. Diurnal variation in symptoms or peak flow. Marked morning dipping of peak flow is common and can tip the balance into a serious attack, despite having normal peak flow at other times.
  3. Exercise: Quantify the exercise tolerance.
  4. Disturbed sleep: Quantify as nights per week (a sign of severe asthma),
  5. Acid reflux: This has a known association with asthma.
  6. Other atopic disease: Eczema, hay fever, allergy, or family history
  7. The home (especially the bedroom): Pets, Carpet,
  8. Occupation: 

Symptoms (Triad)

  1. Intermittent dyspnea,
  2. Wheeze, (is the pathognomic feature Q).
  3. Cough (often nocturnal) Dry cough is the earliest feature Q 

Signs Tachypnea; audible wheeze; hyperinflated chest: hyperresonant percussion note; diminished air entry; widespread, polyphonic wheeze.


Airway obstruction is caused by

  1. Edema and inflammation of mucous membrane.
  2. Excessive secretions of mucus, inflammatory cells and cellular debris.
  3. Spasm of the smooth muscle of bronchi.


  1. Extrinsic - IgE mediated triggered by allergens.
  2. Intrinsic - Non IgE mediated triggered by infection.
  3. Exercise induced
  4. Aspirin induced 

Fig: Enteropathogenesis of bronchial asthma. Triggers of inducers precipitate smooth muscle contraction in a patients with bronchial hyper responsiveness.









Age at onset

3-8 years

Not before 6 months.66%

Present before 3 years

75% present before 3 years. One-fourth of these before 6 months.

Start with a

Viral respiratory infection


Yes / No






History of allergic





Frequency of attack

4-5 per year

1-2 per month

Continuous daily wheeze.


Physical findings

Between attack



Always present

Cheat X- ray



Chest deformation

Lung function

Normal or mild

Reversible change


Lung volume

Marked irreversible change with loss of lung volumes.

Exercise tolerance




Response to



Require intermittent


Require regular aerosolized/systemic steroids.

Growth failure




School attendance

And sleep

Not affected


Severely affected.


Yes, more than 50%

Less than 5-10%

No spontaneous


Resolve by


may resolve



Not needed




Acute severe asthma in children: (status asthmaticus)


Recognition of acute severe asthmaQ

  1. Too breathless to talk.
  2. Too breathless to feed.
  3. Respiratory rate >50 breaths per minute.
  4. Pulse rate> 140 beats/min.
  5. PEF < 50% of the predicted value or the personal best. 

Life threatening featuresQ:

  1. PEF < 33% of the predicted value or the best.
  2. Cyanosis; a silent chest or poor respiratory effort.
  3. Fatigue or exhaustion.
  4. Agitation or reduced level of consciousness

Table: Classification of asthma according to severity



Night time symptoms


Step 4

Severe persistent


Limited physical activity


60% predicted variability >30%

Step 3

Moderate persistent

Daily use β2 agonist attack affect activity

>1 times a week

>60% <80% predicted; variability >30%

Step 2

Mild persistent

>1 time a week but <1 time a day

>2 times a month

80% predicted; variability 20-30%

Step 1


<1 time a week

Asymptomatic and normal PEFR between attack

times a month

80% predicted; variability <20%


Drug therapy-

  1. Beta-2 adrenergics-salbutamol, terbutaline ,salmeterol, formoterol
  2. Corticosteroids
  3. Xanthine derivatives-inhibit phospho diesterase-theophylline ,aminophylline
  4. Atropine derivatives-ipratropium bromide
  5. Mast cell stabilizers-Disodium chromoglycate(inh) ,Ketotifen
  6. Leukotriene inhibitors-Montelukast, zafirlukast
  7. Others- Magnesium sulphate. Ketamine 

Various inhalation devices-

  1. Metered dose inhalers(MDI)-used for >8 yrs
  2. SPACERS-750 ml(>4yrs) and 150 ml(smaller children)
  3. Dry powdered devices- Rota inhalers-not useful for children less than 6 yrs of age
  4. Nebulizers 


  1. Inhibits neutrophils and eosinophils thus prevent lysosomal enzyme damage
  2. Reduce mucosal edema
  3. Inhibit formation of inflammatory mediators
  4. Increase the no of beta adrenergic receptors 

Undesirable side effects of prolonged usage of steroids can be reduced by aerosol through spacers/inhalation devices.

Disodium chromoglycate-

  1. Only inhalation
  2. Only prophylactic- not useful in acute attack*** 
  1. Bronchiectasis

Pathology Chronic infection of the bronchi and bronchioles leading to permanent dilatation of these airways.

Main organisms: H. influenzae Q; Strep. pneumoniae Q; Staph. aureus Q; Pseudomonas aeruginosa Q.



  1. Congenital:
    1. Young's syndrome Q                     
    2. Primary ciliary dyskinesia Q    
    3. Kartagener syndrome. Q
  2. Post-infection:
    1. Measles                        
    2. Pertussis                      
    3. Bronchiolitis
    4. Pneumonia          
    5. TB                                
    6. HIV.
  3. Bronchial obstruction (tumour, foreign body)
  4. Allergic bronchopulmonary aspergillosis (ABPA)
  5. Hypogammaglobulinemia
  6. Rheumatoid arthritis
  7. Ulcerative colitis
  8. Idiopathic.    

Clinical features Symptoms: persistent cough; copious purulent sputum Q, maximum in the morning in a particular posture Q. intermittent haemoptysis Q, Some times haemoptysis alone may be the presenting feature (Bronchiectasis SICCA Q)


Signs: finger clubbing Q; coarse inspiratory crepitations Q, wheeze (asthma, COPD, ABPA).


Complications: pneumonia Q, pleural effusion Q; pneumothorax Q; haemoptysis Q; cerebral abscess Q; amyloidosis Q.



Tests Sputum culture. CXR: cystic shadows, thickened bronchial walls (tramline and ring shadows Q).


HRCT chest:  is the investigation of choice.


Spirometry often shows an obstructive pattern.



  1. Postural drainage should be performed twice daily.
  2. Chest physiotherapy may aid sputum expectoration and mucous drainage.
  3. Antibiotics should be prescribed according to bacterial sensitivities.
  4. Bronchodilators.
  5. Surgery may be indicated in localized disease or to control severe hemoptysis
  1. Cystic fibrosis (CF)

One of the commonest life-threatening autosomal Q recessive conditions affecting,


Caused by mutations in the CF transmembrane conductance regulator (CFTR) gene on chromosome Q. This leads to a combination of defective chloride secretion Q and increased sodium absorption Q across airway epithelium. The changes in the composition of airway surface liquid predisposes the lung to chronic pulmonary infections Q and bronchiectasis.

Clinical features Neonate: Failure to thrive; meconium ileus Q; rectal prolapse, Q

Children and young adults:


Respiratory: cough; wheeze; recurrent infections; bronchiectasis; pneumothorax; haemoptysis; respiratory failure; cor pulmonale,


Gastrointestinal: pancreatic insufficiency Q (diabetes mellitus Q, steatorrhoea Q); distal intestinal obstruction Q syndrome (meconium ileus equivalent); gallstones Q; cirrhosis Q

Other: male infertility Q; osteoporosis; arthritis; vasculitis; nasal polyps; I sinusitis; and hypertrophic pulmonary osteoarthropathy (HPOA Q).


Signs: Cyanosis; finger clubbing Q; bilateral coarse crackles.     


Diagnostic Criteria for Cystic Fibrosis (CF)


Presence of typical clinical features (respiratory, gastrointestinal, or genitourinary)


A history of CF in a sibling


A positive newborn screening test


Laboratory evidence for CFTR dysfunction:

Two elevated sweat chloride concentrations obtained on separate days sweat sodium and chloride Q >60mmoI/L


Identification of two CF mutations


An abnormal nasal potential difference measurement


CFTR, CF transmembrane regulator.

.Faecal elastase is a simple and useful screening test for exocrine, pancreatic dysfunction Q.

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