to differentiate b/w wheezing and stridor....lead to know to make clinical dx for asthma, croup, laryngomalacia, epiglottis...there many noisy breathing....our focus wheezing n stridor....

1. Wheezing & Noisy Breathing
• Presenter:
Azizah Majid
Muhammad Naqib Bajuri
Noor Azwa Sulaiman
Noor Afifah Abd Rahman

2. Content
• Anatomy of respiratory
system
• Stridor
• Epiglottitis
• Laryngomalacia
• Croup
• Wheezing
• Bronchiolitis
• Asthma
• Pneumonia

3. A

6. ..

9. Stridor
abnormal, high-pitched sound produced by turbulent
airflow through a partially obstructed airway at the level
of the supraglottis, glottis, subglottis, and/or trachea.
externally audible sound associated with respiration (It
occurs when a normal respiratory volume of air moves
through narrowed airways, which results in the normal
laminar flow becoming turbulent)
* signifies partial airway obstruction.
a symptom, not a diagnosis or disease, & the
underlying cause must be determined

11. Depending on its timing in the respiratory cycle.
Inspiratory • laryngeal obstruction
stridor
expiratory • tracheobronchial
stridor obstruction.
Biphasic • a subglottic or glottic
stridor anomaly.
In addition to a complete history and physical, as well as other possible
additional studies, most cases require flexible and/or rigid endoscopy to
adequately evaluate the etiology of stridor.

12. Common Causes of Stridor
Croup
Tracheitis
Acute,
Febrile
Epiglottitis
Retropharyngeal abscess
ACUTE
Foreign body
Acute, Thermal injury to airway
Afebrile
Angioneurotic edema
Laryngomalacia
CHRONIC Vascular anomalies
Adenotonsillar hyperplasia

13. Life-threatening Causes of Stridor
Usually Febrile Usually Afebrile
• Epiglottitis • Foreign body
• Retropharyngeal • Angioneurotic edema
abscess • Neck trauma
• Tracheitis • Neoplasm
(compressing trachea)
• Thermal injury

16. Introduction
Acute inflammation in the supraglottic region of
oropharynx with inflammation of epiglottis,
vallecula, arytenoids and aryepiglottic fold.
Due to its place in the airway, swelling of this
structure can interfere with breathing, and
constitutes a medical emergency. Infection can
cause the epiglottis to obstruct or completely
close off the windpipe.

18. Epidemiology
• Greater prevalence in countries without HiB
immunization
• Occur most commonly in children aged 1-6
years

19. • Bacterial infection of the epiglottis, most often:
Haemophilus influenzae type B
• Some cases are attributable to Streptococcus
pneumoniae, Streptococcus agalactiae,
Staphylococcus aureus, Streptococcus pyogenes,
Haemophilus influenzae, and Moraxella
catarrhalis.
• Viral infection: Herpes simplex virus, candida
(immunocompromised pt) & Aspergillus.

20. Pathophysiology
Microorgansim colonize the pharynges through
respiratory transmission from intimate contact
Penetrate mucosal barrier
Invading the bloodstream and causing
bacteremia and seeding of the epiglottis and
surrounding tissues
Acute onset of inflammatory edema of epiglottis.
Edema rapidly progresses to involve the aryepiglottic
folds, the arytenoids, and the entire supraglottic larynx
This may cause the throat structures to push the
epiglottis backward-- continued inflammation and
swelling of the epiglottis, complete blockage of the
airway may occur, leading to suffocation and death.

21. Signs and symptoms
• This dramatic, potentially lethal condition is charac: by an acute
potentially fulminating course of high fever, sore throat,dyspnea,
& rapidly progressing respiratory obstruction.
• Healthy child suddenly develops a sore throat & fever. Within a
several hours, the patient : toxic, swallowing is difficult, &
breathing is labored. Drooling is usually present & the child may
have the tripod position.
• Stridor is a late finding & suggests near complete
airway obstruction. Complete obstruction of the airway &death if
adequate treatment is not provided.
• The early symptoms - insidious but rapidly progressive, &
swelling of the throat may lead to cyanosis and asphyxiation.

23. Diagnosis
• confirmed: direct inspection by direct fibreoptic laryngoscopy,
(carried out in controlled environment like an operating room)
although this may provoke airway spasm. (“cherry red” swollen
epiglottis and arytenoids ) . Tx should not be delayed for this test to
be carried out.
• Classic radiographs of a child who has epiglottitis show the “thumb
sign
• If epiglottitis is suspected, attempts to visualise the epiglottis using
a tongue depressor are strongly discouraged.
• Other test: FBC, pulse oximetry, throat culture (per nasal swab)
(after stabilizing breathing)

24. Normal epigottis “Thumb sign”

25. The most likely differential
diagnostic candidates are
croup, peritonsillar abscess,
and retropharyngeal abscess.
On CT imaging, the
"halloween sign" describe a
normal thickness epiglottis.
It can safely excluded the
acute epiglottitis.
CT imaging show
"halloween sign"

26. Management
• Transferred directly to ICU – intubation (nasogastric tube &
nasotracheal tube)tube removed 24H.
• IV Antibiotic – eg: cefuroxime (after airway is secured& given for
3-5days
• Tracheostomy – severe
• In addition, patients should be given antibiotics, such as second-
or third-generation cephalosporins, either alone or in
combination with penicillin or ampicillin for streptococcal
coverage.
• If allergy to penicillins is present, Co-trimoxazole or clindamycin
is an alternative. In household contacts of any unvaccinated child
infected with H. influenzae, rifampicin is used as prophylaxis

27. Complications
Patients may develop
Pneumonia lymphadenopathy septic arthritis
Pulmonary
Meningitis Empyema
oedema
Pneumothorax Death (asphyxia)

28. Comparison of a normal pediatric airway (bottom) and
airway from a child who died from epiglottitis (top).

29. Prognosis
• The prognosis is good for patients with
epiglottitis whose airways have been secured
& the mortality rate is <1% in these patients
• However, mortality rates as high as 10% can
occur in children whose airways are not
protected by endotracheal intubation

30. WHEEZING

31. • Definition
 An abnormal high-pitched or low-pitched sound
heard-either by unaided human ear or through
stethoscope-mainly during expiration
 Occur as a results of narrowing of airways
- Bronchospasm
- Increased secretion
- Retention of sputum

32. 2 patterns of wheezing
1) Transient early wheezing
2) Persistent and recurrent wheezing

33. Transient early wheezing
• Preschool children
• Virus-associated wheeze aka viral wheeze and
wheezy bronchitis
• Result from small airways to narrow and
obstruct d/t inflammation and immune
response to viral infection
• l/t episodic nature, triggered by viruses cause
common cold

34. • Have decreased lung function from small
diameter
• Risk factor
– Maternal smoking during and/or after pregnancy
– Not related from family hx of asthma and allergy
• More common in males usually resolves by 5
years of age

35. Persistent and recurrent wheezing
• Both preschool and school-aged
• Frequent wheeze triggered by many stimuli
• Presence of IgE to common inhalant allergens
such as house dust mite, pollens, pets
• Associated persistence of wheezing beyond
preschool years

36. • Recurrent wheezing associated with evidence
of allergy to one or more inhaled allergens
termed as atopic asthma
• Have persistent sxs and decreased lung fx.
• Associated with other atopic disease such as
eczema, rhinoconjunctivitis and food allergy;
more common with family hx

37. Causes of recurrent wheeze
• Transient early wheeze
• Atopic asthma (Ig-mediated)
• Non-atopic asthma
• Recurrent aspiration of feeds
• Inhaled foreign body
• Cystic fibrosis
• Recurrent anaphylaxis in child
• Cong. abnormality of lung, airway or heart
• Idiopathic

38. ……

39. BRONCHIOLITIS

41. • Common respiratory illness especially in infants aged
1-6 months old
• 90% aged 1-9 m (rare after 1 year of age)
• Throughout the year, cyclical periodicity with annual
peaks occur in Nov, Dec, Jan
• Majority of children with viral bronchiolitis has mild
illness
– About 1% require hospital admission

42. • Respiratory syncytial virus (RSV) is pathogen in
80% of cases.
• Others human metapneumovirus,
parainfluenza virus, rhinovirus, adenovirus,
influenza virus & Mycoplasma pneumoniae
• Dual infection with RSV and human
metapneumovirus assoc. with severe
bronchiolitis

43. Clinical Features
• Coryzal sxs precede by dry cough & increase
breathlessness
• Feeding difficulty
• Recurrent apnoea
• High risk factor
– Premature develop bronchopulmonary dysplasia
– Cyctic fibrosis
– Congenital heart disease

45. • Age < than 3 months
• Toxic – looking
• Moderate/Severe Chest recession
• Central cyanosis
• Wheeze
• Crepitations on auscultation
• Feeding Difficulty
• Apnoea
• Oxygen saturation <93%
• High risk group

46. Investigations
• Full blood count
• Respiratory viruses identified by PCR analysis of
nasopharyngeal secretions
• Chest X-ray unnecessary but if performed shows
hyperinflation of lungs d/t small airways
obstruction, air trapping & focal atelectasis
• Pulse oximetry to measure & monitor arterial
oxygen saturation continously
• Blood gas analysis performed in severe cases to
identify hypercarbia

47. • General Measures
 Assessment respiratory status and oxygenation
 Maintained above 93% arterial oxygenation
 Monitor sign of respiratory failure
• Nutrition & Fluid theraphy
 Feeding by nasogastric tube
 Intravenous fluids with severe respiratory distress,
cyanosis, apnoea

48. • Pharmacotheraphy
 Inhaled ß2-agonist
 A trial of nebulised ß2-agonist
 Given in oxygen
 May be considered in infants with viral bronchiolitis
 Corticosteroid - may be tried in severe case
 Antiviral agent - Ribavirin is the only for RSV
bronchiolitis
 Antibiotics - to all infants with :
 Recurrent apnoea & circulatory impairment
 Possibility of septicaemia
 Acute clinical deterioration
 High WBC
 Progressive infiltrative changes on CXR

49. • Mist, antibiotics, steroids and nebulised
bronchodilators such salbutamol or
ipratropium not been shown to reduce
severity and duration of illness

50. Prognosis
• Most infants recover from acute infection
within 2 weeks
• Half will have recurrent episodes of cough &
wheeze
• Usually by adenovirus infection, may result in
permanent damage to airways (bronchiolitis
obliterans) but rarely

51. Prevention
• Monoclonal antibody to RSV (palivizumab,
given monthly by intramuscular injection)
reduce no. of admissions in high-risk preterm
infants.
• Good hand hygiene needed to prevent cross
infection to other infants because RSV is highly
infectious.

52. CROUP
ACUTE
LARYNGOTRACHEO
BRONCHITIS

54. DEFINITION
 A viral infection of the upper and lower respiratory
tract
 leading to erythema and edema of the tracheal walls
and narrowing of the subglottic region.
 A result of inflammation of the larynx, trachea and
bronchilaryngotracheobronchitis

55. EPIDEMIOLOGY
 ages of 6 months - 3 years
 peak at 2 years

56. ETIOLOGY
 Pathogen
 most common: parainfluenza virus (74%), (types 1, 2
and 3).
 others :
 Respiratory Syncytial Virus,
 Influenza virus types A and B,
 Adenovirus,
 Enterovirus,
 Measles,
 Mumps
 Rhinoviruses
 rarely :
 Mycoplasma pneumoniae
 Corynebacterium Diptheriae.

57. PATHOGENESIS
VIRAL INFECTION
INFLAMMATION
 Lower airway wheezing
 Vocal cord and pharynxswellinghoarseness of voice
 Trachea redness+swelling barking cough
 Subglottis, tracheaedemainspiratory stridor
RESPIRATORY FAILURE

59. CLINICAL FEATURES
 HISTORY  PHYSICAL
 Low grade fever, cough EXAMINATION
and coryza for 12-72
hours, followed by:
 Sign of respiratory
 Increasingly bark-like distress
cough and hoarseness.
 Stridor
 Stridor that may occur
when excited, at rest or
both.
 Respiratory distress of
varying degree.
 Symptoms are acute onset
and worse at night

60. video

61. DIAGNOSIS
 a clinical diagnosis
 Assessment of severity
Clinical Assessment of Croup (Wagener)
 Severity
 Mild: Stridor with excitement or at rest, with no
respiratory distress.
 Moderate: Stridor at rest with intercostal,
subcostal or sternal recession.
 Severe: Stridor at rest with marked recession,
decreased air entry and altered level of
consciousness.

62. DIFFERENTIAL DIAGNOSIS
 Epiglottitis
 Bacterial tracheitis
 Retropharyngeal abscess
 Foreign body

63. INVESTIGATION
1. Studies show that it is safe to visualise the pharynx
to exclude acute epiglotitis, retropharyngeal
abscess etc.
 In severe croup, it is advisable to examine the pharynx under
controlled conditions, i.e. in the ICU or Operation Theatre.
2. Pulse oximetry is helpful but not essential
3. Arterial blood gas :not helpful because the blood
parameters may remain normal to the late stage. The process
of blood taking may distress the child
4. A neck Radiograph is not necessary, unless the diagnosis is
in doubt, such as in the exclusion of a foreign body.

64. X-ray
 May be essential to exclude differential diagnoses
 Lateral view
 Thickening of pre-tracheal soft tissue – retropharyngeal
abscess
 Air at pharynx-croup: d/t subglottic edema
 Thumb sign: epiglottitis
 AP view
 Angulation of trachea
 Steeple –shaped trachea: croup-subglottic edema

65. Management
1. Indications for Hospital admission
 Moderate and severe viral croup.
 Age less than 6 months.
 Poor oral intake.
 Toxic, sick appearance.
 Family lives a long distance from hospital; lacks reliable transport.
2. Antibiotics are not recommended unless bacterial
super-infection is strongly suspected or the patient is
very ill.
3. IV fluids are not usually necessary except for those
unable to drink.

67. Medication
Corticosteroid (oral, IM,
IV) Nebulised adrenaline
 Moderate to severe
 For all grade (mild
croup
to severe)
 Onset within 30
 Onset after few
mins
hours
 diminished after
 Dexamethasone ~2h
Anti-inflammatory  Rebound effect of
effect lasted up to symptoms may
72 hrs occur

68. COMPLICATION
 VIRAL PNEUMONIA- most common

69. CLINICAL EXAMPLE
 9-month old baby was admitted to pediatric ward with
complaint of acute onset of noisy breathing which is
associated with fever, barking cough and hoarseness. He
also had history of coryzal symptoms like sneezing and
cough for 2 days. He cannot suck well like previously
because of nasal blockage. Immunization is up to date.
Smoking history is present in his father.
 Provisional diagnosis: croup
 Points for:
 Acute onset of noisy breathing
 Fever
 Barking cough
 Hoarseness

70. LARYNGOMALACIA
•MOST COMMON CONGENITAL
LARYNGEAL ANOMALY
•MOST COMMON CAUSE OF
STRIDOR IN INFANTS AND
CHILDREN

71. EPIDEMIOLOGY
 Congenital anomaly of larynx
 an isolated finding in the otherwise healthy infant or
 may be associated with other neurologic disorders such
as cerebral palsy
 Although laryngomalacia is typically thought of as
occurring only in infants, it is occasionally observed in
older children and adults.
 Neurologically impaired children (i.e., those with cerebral palsy) with
poor pharyngeal control
 Exercise-induced laryngomalacia results when enough inspiratory
force occurs during exercise to draw the aryepiglottic folds into the
larynx, partially obstructing the glottis

72. ANATOMICAL LOCATION
 The anatomic abnormality causing the supraglotttic
obstruction of laryngomalacia varies among
infants.
1. anterior prolapse of the mucosa overlying the
arytenoid cartilages (57%)-most common
2. short aryepiglottic folds that tether the epiglottis
posteriorly (15%),
3. posterior collapse of the epiglottis (12%),
4. combination of these findings (15%)

73. On inspiration, the epiglottic
folds collapse into the airway.
The lateral tips of the epiglottis
are also collapsing
inward (arrow)
Progressive airway obstruction
on inspiration.
Note omega-shaped epiglottis

74. CLINICAL FEATURES
 Stridor
 inspiratory,
 low-pitched
 exacerbated by any exertion: crying, agitation, or feeding.
 results from the collapse of supraglottic structures inwards
during inspiration.
 Symptoms usually appear within the first 2 wk of life and
increase in severity for up to 6 mo, although gradual
improvement can begin at any time.
 Laryngopharyngeal reflux is commonly associated
with laryngomalacia.
 high prevalence of gastroesophageal reflux disease
(GERD)

75. DIAGNOSIS
 The diagnosis is confirmed by outpatient flexible
laryngoscopy
 When the work of breathing is moderate to severe,
chest radiographs are indicated.
 Because 15-60% of infants with laryngomalacia
have synchronous airway anomalies, complete
bronchoscopy is undertaken for patients with
moderate to severe obstruction.

76. MANAGEMENT
 Expectant observation
 suitable for most infants because most symptoms resolve
spontaneously as the child and airway grow.
 Laryngopharyngeal reflux is managed aggressively
 severe obstruction that surgical intervention is
unavoidable
 (patients with apparent life-threatening events, cor pulmonale,
cyanosis, failure to thrive) endoscopic supraglottoplasty
can be used to avoid tracheotomy.

77. PNEUMONIA
NOOR AFIFAH BT ABD RAHMAN
027398

78. Contents
• Introduction
• Epidemiology
• Causes
• Pathogenesis
• Clinical features
• Diagnosis
• Investigation
• Management

79. Introduction…
• There is no single definition for pneumonia. It is a clinical
illness defined in terms of symptoms and signs, and its course.
WHO defines pneumonia in terms of febrile illness with
tachypnoea for which there is no apparent cause.

80. – Bronchopneumonia : which is a febrile illness with cough,
respiratory distress with evidence of localised or
generalised patchy infiltrates on chest x-ray
– lobar pneumonia : which is similar to bronchopneumonia
except that the physical findings and radiographs indicate
lobar consolidation.
– Community acquired pneumonia (CAP) : signs and
symptoms of pneumonia in a previously healthy child due
to an infection which has been acquired outside hospital

81. Epidemiology…
• Acute respiratory infections namely pneumonia cause up to 5
million deaths annually among children less than 5 years old
in developing nations.
• Of the estimated total of 12.9 million deaths globally in 1990
in children under 5 years of age, over 3.6 million were
attributed to acute respiratory infections mostly due to
pneumonia. This represents 28% of all deaths in young
children and places pneumonia as the largest single cause of
childhood mortality.
• In Malaysia the prevalence of ARI in children below the age of
five years is estimated to be 28% - 39.3%

82. Causes…
• A specific aetiological agent cannot be identified in 40% to
60% of cases. Viral pneumonia cannot be distinguished from
bacterial pneumonia based on a combination of clinical
findings.
• The majority of lower respiratory tract infections that present
for medical attention in young children are viral in origin such
as respiratory syncytial virus, influenza, adenovirus and
parainfluenza virus. One helpful indicator in predicting
aetiological agents is the age group as shown in table.

84. • Risk factors for developing pneumonia:
 low weight for age
 lack of breast feeding
 failure to complete immunization
 presence of coughing sibling (s) at home
 overcrowding in bedroom

85. Pathogenesis…
• When bacteria infects the pulmonary lobes, the lungs
produce mucus that fills the alveolar sacs.
• In turn, this causes a condition known as consolidation which
occurs when the lungs fill with mucus, reducing air space.
• The reduction in air space makes breathing difficult causing
shortness of breath and labored or shallow breathing.

86. Clinical features…
• Symptoms :
– Fever
– Difficulty in breathing
– Cough
– Lethargy
– Poor feeding
– Localized chest, abdominal, neck pain

87. • Signs:
– Tachypnea
– Nasal flaring
– Chest indrawing
– Chest hyperinflation and wheeze
– (early) diminished breath sound, scattered crackles and
rhonci over affected side
– (effusion, empyema, pyopneumothorax) dullness on
percussion and breath sound markedly diminished
– Lag in respiratory excursion on affected side
– Abdominal distension may be prominent because of
gastric dilation from swallowed air or ileus
– Liver may seem enlarged because of downward
displacement of diaphragm

88. Diagnosis…
• The clinical diagnosis of pneumonia has traditionally been
made using auscultatory findings such as bronchial breath
sounds and crepitations in children with cough.
• However, the sensitivity of auscultation has been shown to be
poor and varies between 33 %- 60% with an average of 50 %
in children.
• Tachypnoea is the best single predictor in children of all ages.
Measurement of tachypnoea is better compared with
observations of retractions or auscultatory findings.

89. • It is nonetheless important to measure respiratory rate
accurately. Respiratory rate should be counted by inspection
for 60 seconds.
• However in the young infants, pneumonia may present with
irregular breathing and hypopnea.

91. Investigation…
1. Chest radiograph
– Chest radiograph is indicated when clinical criteria
suggests pneumonia. It will not identify the aetiological
agent. However the chest radiograph is not always
necessary if facilities are not available or the pneumonia is
mild
2. Complete white blood cell and differential count
– This test may be helpful as an increased white blood count
with predominance of polymorphonuclear cells may
suggest bacterial cause. However, leucopenia can either
suggest a viral cause or severe overwhelming infection.

92. 3. Blood culture
– Blood culture remains the non-invasive gold standard for
determining the precise aetiology of pneumonia. However
the sensitivity of this test is very low. Positive blood
cultures are found only in 10% to 30% of patients with
pneumonia. Even in 44% of patients with radiographic
findings consistent with pneumonia, only 2.7% were
positive for pathogenic bacteria.
4. Culture from respiratory secretions
– It should be noted that bacteria isolates from throat swabs
and upper respiratory tract secretions are not
representative of pathogens present in the lower
respiratory tract. This investigation should not be routinely
done.

93. 5. serology tests
– serological studies should be performed in children with
suspected atypical pneumonia as Mycoplasma
pneumoniae, Chlamydia, Legio nella and Moxarella
catarrhalis are difficult organisms to culture.
6. Other tests
– Bronchoalveolar lavage is usually necessary for the
diagnosis of Pneumocystis carini infections primarily in
immunosuppressed children. It is only to be done when
facilities and expertise are available. If there is significant
pleural effusion diagnostic, pleural tap will be helpful.

94. Management…
• Assessment of severity of pneumonia **
• Assessment of oxygenation
– The best objective measurement of hypoxia is by pulse
oximetry --> avoids the need for ABG

95. • Criteria for hospitalization
– <3 months old regardless severity
– Fever(>38.5), refusal to feed and vomiting
– Fast breathing with/without cyanosis
– Associated systemic manifestation
– Failure of previous antibiotic
– Recurrent pneumonia
– Severe underlying disorder

96. • Antibiotic therapy
– Depends on age, severity, radiographic findings, local
epidemiology of pathogens, sensitivity and resistance of
organism
• Staphylococcal infection : cloxacillin
• Streptococcus pneumonia : penicillin, cephalosporin
• Atypical pneumonia : macrolides (erythromycin, azithromycin)
• Severe CAP : 2nd or 3rd generation cephalosporin and macrolides
• Supportive therapy
– Fluids  should not overhydrated (ADH ususally increase in severe
pneumonia)
– Oxygen  maintain SPO2 >95%
– Analgesic and temperature control  PCM
– Chest physiotherapy  assist removal tracheobronchial secretion

97. • Outpatient management
– Fast breathing but no chest indrawing
– Oral antibiotics
– Advice to return in 2 days or earlier if child getting worse

98. BRONCHIAL ASTHMA

99. Introduction…
• Def : chronic airway inflammation leading to
increase airway responsiveness that leads to
recurrent episodes of wheezing,
breathlessness, chest tightness and coughing
particularly at night and early morning

100. Causes…
• Bronchial asthma triggers may include:
– Smoking and secondhand smoke
– Infections such as colds, flu, or pneumonia
– Allergens such as food, pollen, mold, dust mites, and pet dander
– Exercise
– Air pollution and toxins
– Weather, especially extreme changes in temperature
– Drugs (such as aspirin, NSAID, and beta-blockers)
– Food additives (such as MSG)
– Emotional stress and anxiety
– Singing, laughing, or crying
– Perfumes and fragrances
– Acid reflux

101. Pathogenesis…
Environmental Bronchial
Bronchial
factors + genetic hyperactivity +
inflammation
predisposition trigger factors
Edema, Symptoms: cough,
bronchoconstriction wheezing, chest
Airway narrowing
, excess mucus tightness,
production breathlessness

102. Clinical features…
• Symptoms:
– Shortness of breath
– Tightness of chest
– Wheezing
– Excessive coughing or a cough that keeps child awake at
night
• In acute episode:
– Breathless during rest
– Not interested in feeding
– Sit upright
– Talk in words (not sentences)
– Usually agitated

103. • Findings during a severe episode include the
following:
– Respiratory rate is often greater than 30 breaths per
minute
– Accessory muscles of respiration are usually used
– Suprasternal retractions are commonly present
– The heart rate is greater than 120 beats per minute
– Loud biphasic (expiratory and inspiratory) wheezing can be
heard
– Pulsus paradoxus is often present (20-40 mm Hg)
– Oxyhemoglobin saturation with room air is less than 91%

104. Investigations…
• Lung function test increased functional residual capacity
• Peak expiratory flow rate (PEFR)  >5 y/o
• Bronchodilator reversibility test  improved 10-15% after
inhalingbronchodilator)
• Skin prick test  to diagnose the atopy
• Chest x-ray  usually normal -TRO other conditions

106. The radiographic changes of asthma are those of
overexpansion (flat diaphragm, square chest shape)

107. Managements…
• Bronchodilator therapy
 Inhaled B2 agonist are most commonly used and most
effective bronchodilators.
 Short acting(relievers): salbutamol or terbutaline (effective
for 2-4hr)
 Long acting (LABAs): salmaterol (12hr)
 They are not used in acute asthma and should not be used with
inhaled corticosteroid
 Useful in exercise induced asthma

108. • Inhaled corticosteroid
 Most effective inhaled prophylactic therapy.
 Decreases airway inflammation, resulting in decrease
symptoms, asthma exacerbations and bronchial
hyperactivity
 It can produced systemic side effects, including impaired
growth, adrenal suppression and altered bone
metabolisms, when high doses are used
• Add-on therapy
 Leukoriene receptor antagonist (montelukast); can also be
used in older children when symptoms are not controlled
by the addition of the LABA
 Slow-release oral theophylline is an alternative; but
incident of side effects (vomiting, insomnia, headaches,
poor concentration) -not commonly used in children-

109. • Other therapy
 Oral prednisolone
 Anti-IgE therapy (omalizumab)
 Antibiotics – most are of no value in the absence of
bacterial infection>> recent data suggest that macrolides
antibiotic (erythromycin) may have specific role in asthma
management
 Antihistamine – useful in the treatment of allergic rhinitis
• Allergen avoidance and other pharmacological
measures
 Avoid allergens
 Allergen immunotherapy is effective for treating atopic
asthma
 Parents to avoid smoking in the house

110. References…
• Illustrated textbook of paediatrics, 4th edition
• Paediatric protocols for Malaysian hospital
• Clinical practice guidelines (CPG)

112. Thank you
very muchh
for your
kind
attention
^__^