Lower Respiratory Tract Infections

Dr. Ong

LUNG PHYSIOLOGY AND COUGH

AIRWAY OF ADULT VS PEDIATRICS COUGH RECEPTORS
Narrowest portion of airways Those pink spots would represent the cough receptors, and in
 Adult – vocal cords the diagram where do we find it in majority? LARGE AIRWAYS
 Pediatrics – Cricoid cartilage from the trachea down to the major bronchi. Notice that the
Airway diameter: pediatric < adult region of the middle ear we have cough receptors, so if we
 Significance: Pediatric px will suffer more than adult if there clean our ears getting deeper will stimulate it. The lung
is insult in the airway. parenchyma per se has little cough receptors and most of them
 Hypoxemia develops due to increase resistance of the are found in the airways
narrow airways
 majority found in the upper or large airways (e.g.
ANATOMY trachea, bronchi)
 -Also present in the middle ear, found in the airways but
NOT in the lung parenchyma

Physiology: anatomic, physiologic and immunologic defenses

The body has many anatomic defenses in respiratory tract,
starting with the nose, hair and the terminal bronchioles has
defenses exemplified by the presence of ciliated epithelium
lining the respiratory system
Physiologic defenses of the body:
Cough and sneeze reflex; inhaling an irritant triggers them both,
they serve as important defenses in the body and not meant to
be suppressed.
Immunologic diseases:
Major immunoglobulin in the respiratory tract? IgA

ACUTE VS CHRONIC COUGH

Acute Cough Chronic cough
 common feature of LRTI  30 days
diseases  e.g. TB, asthma
 < 30 days duration
Schematic diagram of the respiratory tract, remember in
anatomy the respiratory tract would start from the nose down to
For every disease, know the:
your terminal bronchioles in the lungs, theoretically you can
 most common pathogen
divide the respiratory tract in 2: Upper and Lower respiratory
 Age
tract
 Clinical manifestations
 Diagnostic procedure
Respiratory tract: nose to alveoli
 Drug of choice
1st line defense:
There are many diseases in the respiratory system and all of these
 vibrissae, ciliated lining epithelium, physiologic
will have one common manifestation which is COUGH. Our task
mechanisms (coughing, sneezing), immunologic
is to find out if a patient is presented with cough, so what are the
mechanisms
underlying cause of the cough? So every disease discussed
throughout the topic we must know the pathogen and the drug
Larynx
of choice to be given. Always consider the age of the patient,
 boundary between upper and lower airways
which the specific pathogen would be evident to a patient
 consists of 9 cartilages (3 paired and 3 unpaired)
depending on the certain age given the features, even the
 Vocal cords, thyroid c, cricoid c, arytenoids, cuneiform, diagnosis would be different if the age of the patient is
corniculate changed.
What are the salient features in combination with cough that we
LOWER RESPIRATORY TRACT
are dealing with the disease? So as we go along we are going
- consists of everything inside the thoracic cavity to identify those salient clinical features of the different diseases.
Then decide if we need laboratory findings, but some diseases
The boundary of the respiratory tract is the larynx, so anything don’t require these procedures and the diagnosis can be
ABOVE the larynx is the UPPER respiratory tract and everything explained by simple history and physical exam.
below is the LOWER respiratory tract
In some literature, respiratory system is divided differently, airways ADVENTITIOUS BREATH SOUNDS
or lung parenchyma; thus from the nose to the terminal
Adventitious Lung Duration Pitch TIming
bronchiole are part of the airways and we have the 2 lungs.
Sounds Sounds
Everything inside is INSIDE the thoracic cavity is THE LOWER
Wheezing Continuous High Inspiratory
RESPIRATORY TRACT and everything outside it is the UPPER
Expiratory
RESPIRATORY TRACT
Rhonchi Continuous Low Inspiratory
Expiratory
Stridor Continuous High Inspiratory
Crackles Discontinuous Inspiratory
the sound is heard during INSPIRATION it is EXTRATHORACIC,
in contrast if EXPIRATION then it is INTRATHORACIC

EVANGELISTA, FALCON, MARQUEZ, MIRASOL (3B) 1

 Management
PROVEN TO BE EFFECTIVE:
Oxygen
Among all the diseases we are going to talk about, if they have
respiratory distress as a salient manifestation, it is understood that
we must give oxygen to the patient. DOB = GIVE OXYGEN
If the patient has difficulty of breathing what happens to the
intake of food, Affected? Yes, so chances are if the patient has
a pulmonary problem in the days preceding the onset of
respiratory distress, this patient may have not been eating well.
Fluids
 but sole water therapy has really not been proven to make
secretions less viscous
Misconceptions: If cough, is it not indicated to drink fluids?
Drinking fluids would not benefit it, but won’t do harm either.
Drinking cold water wont exacerbate the cough nor eating
sweets, the problem reflects on what are you drinking or eating.
It could be a cause of allergy,
If febrile, the have increased INSENSIBLE water loss. If
tachypneic, there will be further increase in SENSIBLE water loss.
So all of these combined together would put the patient at risk
of dehydration due to the pulmonary problem it is understood to
give fluids either oral or intravenous. If the present with fever then
give paracetamol.
COUGH/COLDS MEDICATIONS
 RULE OF THUMB: Better to give a drug that only has one
action. Do not give combination drugs.
In the Philippines, patients don’t want to leave the clinic without
a prescription. So it’s important for us to know the cough and
cold medicines in the market. Why won’t be discussed in the
topic? Because if you browse the nelson’s book, you’ve noticed
that the cough and cold medicines are not written because
studies show that they do not work particularly the cough
medicine. But in the Philippines we have to know them.
Mucolytics (e.g. Carbocysteine Solmux)
 breaks down the disulfide bonds in the secretions to make
them less viscid and easier to expectorate; however, no
clear cut benefit in children
Most important cough medication in the market? Tuseran which
is the top selling even alone could save the market of the
company. Tuseran contains mucolytic which liquefies the
phlegm and anti – histamine if given in a disease not caused by
an allergy its effect will make the secretion less.
If we give an anti-histamine caused by an allergy then the
patient’s condition will improve but if given to a manifestation
caused by a viral infection it is going to make the secretions
more viscid (more thick), thus the effects of the drug are
antagonizing each other.
Expectorants (e.g. Guaifenesin Robitussin)
 it is really not expected for children to be able to
expectorate; however, justified use when enables child to
sleep restfully at night
Expectorants (Guaiafenessin – formerly Glyceryl Guaiaculate)
Robitussin, Ventolin
– it is expected to promote expectoration so the patients would
be able to cough out phlegm.
Anti-tussives (e.g Dextromethorphan)
 not used in children because cough is a physiologic
defense mech and you do not want to suppress
Antitussives (dextromethorphan)
Anti cough – prevent coughing (remember that cough is a
physiologic mechanism, and not supposed to suppress it) but
there are exemptions in such that the patient can’t sleep well at
night due to persistent coughing then the antitussive is indicated.
Another example when a child during coughing aggravates
abdominal pain when present.
EVANGELISTA, FALCON, MARQUEZ, MIRASOL (3B)
In majority of the drugs they relieve the cough but the problem is
they do not treat the underlying cause. What is important as
clinicians is to know what causes the cough and manage the
underlying problem rather than treating the symptomatic cough
per se.
Neozep (phenylephrine + antihistamine)
 antihistamine is only good for cough with allergic etiology
(like asthma) but if it is non-allergic, it will increase the
viscosity of the cough and make it harder to expectorate.
Fever relief: acetaminophen, paracetamol.
Component of Neozep (Phenylephrine), generally all
decongestants in the market contains phenylephrine; it was
used to be phenylpropanolamine but it was banded by the US
FDA because of the alleged side –effects seen in adult women
taking it as a reducing drug in high doses, side effects noted was
bleeding. But in the usual dose of the decongestant it is rare to
get the side effects. So if a patient asks you a drug for cold, it is
recommended to give a drug with a single component with 1
active drug preparation (over drug combinations)
If there (+) secretions in colds do we need to give a
decongestant? No, but anti – histamine will make the secretions
more viscid to lessen it. It contains anti – histamine, noting for its
side –effects especially 1st generation includes CNS depression
an drowsiness.
2nd generation: Loratadine and Citirizine, with lesser side – effects.
So whatever benefit the drug has given to the patient for
instance is neozep, the beneficial effect is not secondary to the
anti – histamine properties but to its anti – cholinergic capabilities
but not present in NEWER anti – histamines.
If you’re going a drug to treat the cold, your decongestant will
try to loosen your secretions, in contrast to anti – histamine will
make the secretions more viscid thus opposing each other. So
it’s not therapeutic however people will always ask for advice for
cough and colds and give them sound advices.
STANDARD HOME MEDICATIONS:
Vitamin C
 shortens the duration of cough and colds but not proven
to prevent it
Vitamin C: improve body’s defenses, according to belief for
children, reduces the chances of coughs and colds (Ceelin). But
studies have shown that vitamin C will not prevent us from not
having frequent cough and colds and the proven benefit is to
shorten its duration and lessens severity of the colds.
Steam inhalation
 can cause burns especially among infants when not
done correctly; there are safer options!
Steam inhalation
Prepare a basin with steaming water while covered in towel to
trap the steam, the water inhaled should preferably be NSS or
water mixed with table salt. It works under the effect of the Salt
making the secretions less viscid but doesn’t work like that, the
process is that the salt serves as an irritant, therefore when we
inhale it would stimulate sneezing and coughing that would
facilitate evacuation of the phlegm and the nasal secretions for
relief of breathing.
Lozenges
Strepsils, decuadin, Fisherman’s friend
 taken primarily for the sore throat but not for the cough
Saline gargle
 Primarily for the sore throat.
 Commercial preparations are available such as bactidol,
astring – o – sol, ora care.
2
Oil based (in provinces)
 Oil – based preparations in steaming water (may cause
Lipoid pneumonia). It causes oil deposits in the lung
parenchyma.
 The needed treatment for these is lung transplant so oil –
based is not recommended for a child with a pulmonary
problem.
 Taking a bath with cough? Yes
Vicks Vaporub
 oil based and not good for internal application
 covers skin pores -> traps heat -> vasodilation
 Vicks Inhaler: should be used correctly, do not insert inside
the nostrils.
Vicks vaporub
- For external use only, causes vasodilation for ease of breathing
ACUTE INFLAMMATORY UPPER AIRWAYS OBSTRUCTION (CROUP SYNDROMES)
 characterized by bark-like or brassy cough with stridor (hoarse high pitched inspiratory sound)
EPIGLOTTITIS (SUPRAGLOTTITIS)
Medical emergencies especially in children because of a
common clinical feature which is STRIDOR.
If you ask the patient to open his/ her mouth this is what would
you expect to see, (UVULA, PHARYNGEAL TONSILS) the epiglottis
is not ROUTINELY seen but using a tongue depressor may make it
grossly appear as a flop that is covering your glottic opening
preventing food from entering the airway as we eat.
Located anteriorly, the trachea and posteriorly the esophagus.
ARYTENOIDS
TRUE VOCAL CORDS AND FALSE VOCAL CORDS
 covered by the epiglottis. The epiglottis could be inflamed
known to be as epiglottitis. Since it is located above the
glottic opening it is termed to as supraglotitis.
CAUSATIVE AGENT
 H. influenzae (type B), S. pyogenes, S. pneumoniae, S.
aureus
When you hear the diagnosis of epiglottitis the first organism you
should consider is H. influenza particularly type B. In the US and
other western countries where the vaccines are given for free.
They have very good coverage for Hib vaccine so that the
incidence of the diseases cause by H. influenza has markedly
decreased. In the Philippines, some Health centers have Hib
vaccine but cannot sustain it due to the lack of government
funds.
ONSET
 2-4 y/o (does not preclude adulthood)
In children 2 – 4 years of age however in literatures would tell
you that the diseases are discovered as young as 1 year old
and as old as 7 years of age
Features that tells you that this is epiglottitis: Acute onset of fever
that is high, severe throat pain. Because of epiglottis being
swollen being at the top of the glottic opening, then the patient
would manifest difficulty of breathing due to obstruction of the
airway. These in turn would cause air hunger, restlessness, very
toxic – looking patient
CLINICAL FEATURES
 Acute onset: sudden high grade fever, sore throat
 Rapidly progresses to air hunger, restlessness, and toxic
appearance
 Hyperextended neck – attempting to breathe
 Stridor – signals narrowing of airways
 4Ds: Dysphonia, Dyspnea, Dysphagia, Drooling
o Considered as EMERGENCY situation
When take examinations, patient presenting with stridor and
explained the 4 clinical manifestations (dyspnea, dysphonia
(pain while speaking), respiratory distress, dysphagia and
EVANGELISTA, FALCON, MARQUEZ, MIRASOL (3B)
Misconceptions:
If cough, is it not indicated to drink fluids?
- Drinking fluids would not benefit it, but won’t do harm either.
Drinking cold water wont exacerbate the cough nor eating
sweets, the problem reflects on what are you drinking or eating.
It could be a cause of allergy,
- It can be helpful especially with fever (cold shower or tap
water). Indicated to those also with pneumonia unless not
ambulatory (do TSB or tepid sponge bath)
Could rain cause colds? No
- During rainy seasons, viral infections are common and it is
everywhere so it is easily acquired.
drooling of saliva. When these problems are present along with
stridor, this will be clue that the patient has epiglottitis. So most
exam questions will give these clinical manifestations
Tripod Position
 shoulders up,
 leaning forward,
 arms used for support,
 chin up
-- position assumed to attempt to
breathe
Because of respiratory distress, the patient will do certain
maneuvers in order to improve oxygenation, by extending the
neck making the airway patent. Another maneuver is the TRIPOD
position, will sit hunched forward with both arms touching the
knee with a hyperextended neck, usually observed in patients
with epiglottitis.
Philippine data shows low incidence, probably not recognized
but why do we have to study it? Because its often asked in major
examinations and also to prepare us in global competence and
diseases that are seen not only in the Philippines but around the
world.
DIAGNOSIS
1. Clinical with high index of
suspicion
2. Direct Laryngoscopy: insert into
oral cavity to visualize glottis
markedly inflamed (large, cherry
red, swollen)
 do with caution because it
might trigger gag reflex and
cause arrest
3. Lateral Xray of the Neck - THUMB
sign
How to establish diagnosis:
- History is suggestive, suddenly a patient complained with high
fever with pain while swallowing, and if you asked the patient to
open his mouth you would observe the large cherry – red swollen
epiglottis. This would caution us that this may be epiglottitis but in
order to confirm the diagnosis we should do x – ray and note for
the tram sign. Thumb sign
In x – ray the air is black (lucent) and solid and liquid would
appear as white (opacities) in the x – ray. This is the cervical
spine, oral cavity, column of air (pharynx) down to the trachea
but appear as narrowing (the lucency off the trachea is getting
thinner as it goes down) indicating that air flow to the lungs is
3
limited because of the swollen epiglottis, if you can see it looks
like a thumb (“thumb sign”) so it will give us a hint that it is
epiglottitis and no other disease would give us that impression
and its treated as an emergency.
Remember that the priority is to secure the airway or intubate if
need. Word of caution if the patient is suffering from upper
airway obstruction with stridor (parang umeere ang ingay) that
the sound appears frightening for the parents considering upper
airway obstruction.
Please be advised not to poke the tongue when assessing the
mouth using a tongue depressor unless in a facility which CPR
can be performed. The usual response when being assessed with
a tongue depressor that patient may experience gag and
stimulation of the vasovagal reflex that may cause reflex
bradycardia and eventual respiratory arrest. So do not attempt
to look on the throat of the patient without oxygen.
CROUP (ACUTE LARYNGOTRACHEOBRONCHITIS) - most common
CAUSATIVE AGENT
 Parainfluenza, influenza, adenovirus, RSV, measles
ONSET
 Older infants and toddlers (< 5 y/o)
Most common among diseases causing upper airway
obstruction is croup or acute laryngotracheobronchitis. The
larynx, trachea and bronchi is involved. Caused by usually the
viruses. Seen in children as early as 3 mos up to 5 yrs of age, most
of the cases in clinical practice that it is seen in children at 2
years of age. It is very common during the rainy season.
CLINICAL FEATURES
 1-3 days: common cough and colds
 Sneezing, rhinitis, rhinorrhea
 low grade fever
 Barking cough (after 1-2 days)
 Hoarseness
 Stridor
 Worse sx at night
 Resolves in a week (viral infxn, so no DOC)
Appear as an upper respiratory tract infection, cough, cold and
fever, sudden barking type of cough, that is very dry and harsh and
more painful compared to productive. It is distinguished from
productive aside the fact that children aren’t able to cough phlegm
properly, so we can tell the differences by the sound it produces.
Children could also either expectorate, vomit or swallow their
phlegm and goes out with the stool so it’s not unusual for patients
with pulmonary problems to develop soft stools, so it’s not necessary
to scold children who aren’t able to expectorate the phlegm.
Hoarseness of the voice is clue that there is a problem in the larynx
and presents as stridor. Symptoms are worse at night.
DIAGNOSIS
 Clinical
 Neck X- ray (frontal
view):
Steeple/Pencil sign
How to establish the
diagnosis
EVANGELISTA, FALCON, MARQUEZ, MIRASOL (3B)
MANAGEMENT
1. Medical emergency -> Secure airways - intubation,
tracheostomy (puncture cricothyroid membrane)
2. Antibiotics
 Ampicillin or Chloramphenicol - DOC for H. influenza
 Ceftriaxone - for strains resistant to ampicillin (7 - 9 days)
 Accdg to Nelson: also Cefotaxime and
Meropenem
 Rifampicin prophylaxis for other members of household:
once daily for 4 days
The most common cause of epiglottitis is H. influenza so the drug
of choice is ampicillin or chloramphenicol. When you read
nelson you can also give ceftriaxone and so forth, due to high
resistance to ampicillin but locally still works. For instance all
patients who died in Quezon City used Ampicillin as medication,
henceforth you wouldn’t use it in the first place rather use a
stronger antibiotic. Using a stronger antibiotic won’t make you a
better physician so it’s important why it is necessary to tell the
patient which medication is indicated to be or not to be given.
Epiglotitis is a very virulent and infectious disease, so anyone who
had contact with the child should receive prophylaxis of
rifampicin that is given for 4 weeks.
Strictly speaking, this can be establish by history taking and
physical exam. Clinical features are very distinct such as cough,
cold and fever and sudden barking of cough and with stridor will
serve as a giveaway for diagnosis. In the event that you are not
sure, you can always request an x – ray of the neck.
Frontal view of the neck; so if you look on the spine, you can see
lucency. Spine, vertebral column, with a line of lucency in the
middle (represents air in the Trachea). Trace the trachea up,
there is a sudden narrowing (Stipple sign; Pencil sign) looks likes a
point of the pencil
MANAGEMENT
 NO DOC!
 Secure airways
 Racemic Epinephrine - better because hydrophilic
- However, this is not available in the Phils. Only the
dextrorotatory form in NSS is available, one dose only
Management involves securing the airways, racemic epinephrine,
and supportive management.
Isomers, are mirror image of each other. Can be dextro (Hydrophilic)
or levo (Hydrophobic). Therefore if a substance is hydrophilic it will
dissolve in water, otherwise if hydrophobic it won’t dissolve in water.
Locally available epinephrine is hydrophobic, so there is no available
epinephrine in the Philippines, nearest is in Singapore. The racemic
epinephrine is effective in just 1 dose as if nothing happened to the
patient and the response is very dramatic so the patient is sent home
afterwards. However if there are no improvements don’t give a
second dose of it anymore since it won’t work anymore. In
socioeconomic concerns, we prefer using epinephrine but not
everyone is recommended to have it because it’s not part of
standard management.
Standard management
– if this is the diagnosis, these should be the step – wise procedure to
be done to the patient. If the procedure was not followed correctly
and something happened you may be liable for that action.
 Steroids
- Dexamethasone - tablets or parenteral (IM); give
then observe for 4-6 hours
- Budesonide – inhalational, one dose
 Improvement after 1 week
Other options are available such as steroids, Dexamethasone IV,
Budesonide (Inhalation), there are many showing good response to
drugs because they are available locally. So in the US if diagnose
with croup you won’t be admitted automatically, the patient will be
given a dose of Dexamethasone and observe in ER for 4 to 6 hours. In
the Philippines we cannot do that because of the number of patients
occupying the ER which is overcrowding.
Mild cases may not be admitted, it is self – limiting and usually after a
week the patient is okay.
4
 SPASMODIC CROUP
CAUSATIVE AGENT Another variant: spasmodic croup; the features are similar to
 Viral (Parainfluenza); Allergy; Psychological croup but no fever. Has cough, colds, fever in the beginning and
eventually cough becomes hacking or barking. History findings
CLINICAL FEATURES reveal that the child is okay in the morning but once asleep
 Presents similar to croup of LTB he/she will walk up due to stridor. In the provinces the most
- barking cough, dyspnea, noisy breathing common mode of transportation used is motorcycles, so usually
 How to differentiate: No viral prodome (cough and colds) during the evening the air is cold, so during the travel time the air
or fever flows to the child which is therapeutic for the child so if they
 Usually occurs at night arrive to the hospital they would appear okay and set home. So
- How to diff: no symptoms prior to sleeping, unlike history findings could be a giveaway sign that it is spasmodic
in croup croup.

MANAGEMENT
 Most cases improve in a few hours
- sometimes on the way to the hospital px improves
d/t exposure to the cold night air
- improvement depends on how soon humidified
air is introduced

BACTERIAL TRACHEITIS
DESCRIPTION Usually it is being though as possible complication of respiratory
 Does not involve epiglottitis, but like the others is capable of tract infection. In general, a viral infection would predispose
causing life-threatening airway obstruction secondary to a bacterial infection because cilia is being
 Often follows viral RTI denuded caused by viral organisms, when its denuded the
respiratory epithelium is exposed so if the cilia is not there it is
CAUSATIVE AGENT easy for the organism to infect the epithelium.
S. aureus, M. catarrhalis, H. influenzae, anaerobes Distinguishing features of bacterial tracheitis is not that toxic but
there is stridor, no drooling or difficulty in swallowing and the
ONSET usual characteristic is that the patient has a lot of copious
purulent secretions that is yellowish to greenish that will tell us its
5-7 y/o
bacterial (epiglottitis, croup, spasmodic group has less secretions
and will serve as a distinguishing problem of the disease). The
CLINICAL FEATURES
diagnosis is based on clinical, the symptomatology of the
 Brassy cough, high fever, stridor disease and the presence of the purulent secretions. Laboratory
 With copious, thick, mucopurulent secretions exam is not necessary if clinical impression is bacterial tracheitis.
 How to differentiate from other diseases - can lie flat on If we are dealing with staph and increasing incidence of MRSA
bed, NO drooling, NO dysphagia = NOT TOXIC LOOKING so we are considering giving the right antibiotic and if started will
improve 2 – 3 weeks in time. They will manifest difficulty in
DIAGNOSIS breathing. It is a very benign disease, inflammation of the larynx.
 based on evidence of bacterial infection (e.g. high grade It is viral in origin and since the larynx is involve it will show voice
fever and purulent phlegm) changes so hoarseness of the voice is present. So if there is
 X-ray is unnecessary laryngeal involvement there is voice changes. They don’t usually
manifest difficulty breathing unless we are dealing with very
MANAGEMENT young patients. Since it’s benign, it won’t be a reason to absent
 Vancomycin or βlr antibiotics (Cefotaxime, Cefuroxime, from school, work and be excused unless if you’re an
Oxacillin) --- Impt: know your local resistance patterns! announcer. Management is supportive symptomatic, includes
 Clinical improvement in 2-3 d gargle, antiseptics, lozenges use in laryngitis.

ACUTE LARYNGITIS
DESCRIPTION Toxic looking that will manifest with DOB. This is an exception. It is
 Inflamed larynx -> narrowed lumen -> ↑airway resistance a benign disease – inflammation of the larynx. Viral in origin. If
 Main fnc of larynx: Voice box/ Phonation, passage of air the larynx is involved, there will be voice changes – hoarseness of
 MoT: Droplet Nuclei voice.
 Benign! ---does not cause difficulty of breathing If there is no hoarseness of voice, the larynx is not involved
(Other benign condition: bronchitis) Laryngeal involvement – voice changes; very young patients
presents with difficulty of breathing
CAUSATIVE AGENT It is a benign condition – cannot be used as an excuse sa work
 Parainfluenza viruses unless ikaw ay singer. Lol
DIAGNOSIS
ONSET  Clinical – Hx and PE
- important to recognize recurrent laryngeal
 2-4 y/o infections -> predisposed to develop Rheumatic
Heart Disease
CLINICAL FEATURES  Labs not necessary
 URTI: Sore throat
 (+/-) fever MANAGEMENT
 cough  DoC: None, it will resolve spontaneously.
 (+/-) colds  Symptomatic and Supportive Treatment: Lozenges, ginger
 hoarse voice (Differentiates it from tonsillitis and pharyngitis Management: supportive, symptomatic
= no hoarseness)

EVANGELISTA, FALCON, MARQUEZ, MIRASOL (3B) 5

 DIPHTHERIC LARYNGITIS – very infectious
DESCRIPTION DIAGNOSIS
 Confirmed by smear (swab pharyngeal area)
 extension of the infection to the larynx isolate the organism – swab in pharyngeal study

CAUSATIVE AGENT MANAGEMENT

Corynebacterium diphtheria (incubation period of 2-5 days)  Isolate the patient
 DOC: (always administer TOGETHER!)
CLINICAL FEATURES - diphtheria antitoxin
 fever, sore throat, fetor oris (bad breath)  distinguishing - penicillin G or erythromycin -> to neutralize the bound
feature toxins
 bull neck appearance
 greyish white membrane/plaque on the tonsils In the Philippines we see patients with diphtheria but scarce, it is
common mistake is that they remove it, that results to a communicable disease and most hospitals won’t allow
bleeding admission of these kind of problems even in the private rooms
 hoarseness, stridor San lazaro – pavilion with diphtheria
Very communicable diseas; not all hospitals are allow
to admit pts with diphtheria
RETROPHARYNGEAL ABSCESS
DESCRIPTION  Hx of prior ENT infection – clue when dealing with retro
 infection of deep neck tissue between the pharynx and pharyngeal abscess
cervical spine (posterior to esophageal wall) o Sore throat, took meds, felt a little better, subside
ang symptoms for 1 week, however after few days
ETIOLOGY nag recur ang fever and this time mas severe ang
 prior infection in nasopharynx, paranasal sinuses, middle coughing
ear  Features – fever - high grade, do not feed, dehydrated,
 extension from oropharyngeal infection neck pain, stiffness of the neck (test for neck rigidity – up,
 dental infection down; check for suffleness – left to right), muffled voice,
 cervical osteomyelitis stridor, bulging of the retropharyngeal wall due to abscess –
cover the glotic opening and the esophagus
At the back of the pharynx  Should be differentiated from epiglottitis and foreign body,
- The space that separates the esophagus from the trachea meningitis
- Rich in lymph nodes that is why many microorganism can
easily transfer DIAGNOSIS
o Eg. Dental carries – org can move from one area PE: bulge on pharyngeal wall
to another thru the lymph nodes – usually may - DO NOT use tongue depressor -> can trigger gag
come from tonsillitis, trauma, dental infection, reflex and cause arrest
infection from cervical spine Soft tissue neck films
- shows ↑depth of tissue bet. esophagus and trachea
ONSET - Not required if you can already dx by clinical
 3-4 y/o (because nodes involute before 5 y/o) Lateral X-ray or Neck CT scan also possible
- Not seen in children >5y/o bec other lymphoid organs Dx – hx, PE, bulging of the pharyngeal wall, x ray of neck soft
stayed awork? Kaya hindi sila ganun kaimportante tissue (large space between the pharynx and the cervical spine
- <5y/o tonsils, lymph nodes are important due to abscess)
Neck CT scan
CAUSATIVE AGENT
Usually bacterial: group A Strep, Anaerobes S. aureus DIFFERENTIAL DIAGNOSIS
 GAS - mc pathogen  FBA Foreign Body Aspiration
 Abscess – staph  Epiglottitis (sore throat, narrowed airway space)
 Meningitis (neck pain, stiffness, rigidity)
CLINICAL FEATURES --- If (+) hx of prior ENT infection, think of retropharyngeal
 Fever – usu. high grade abscess!!!
 Irritability
 Dysphagia -> Dec food intake MANAGEMENT
 Sore throat, neck pain, torticollis  3rd gen Cephalosporin + ampicillin-sulbactam or
 Muffled voice clindamycin
 Stridor  Drainage ONLY IF: distressed, failure to improve with IV
 Distress, cyanosis antibiotics, for culture study on specimen
Mgt – do not drain – can cause aspiration or ingestion – spread
the infection

EVANGELISTA, FALCON, MARQUEZ, MIRASOL (3B) 6

 FOREIGN BODY ASPIRATION
DESCRIPTION
 aspiration of small objects (e.g. nuts, beads)
 may cause obstruction = MEDICAL EMERGENCY
ETIOLOGY
 Organic objects (80%) – peanuts, seeds - more problematic
if they dissolve -> pneumonitis
 Inorganic objects (20%) – earrings, whistle, beads
Note if the aspirated object is organic(can cause more damage
– can cause tissue breakdown, oils will be released that can
cause pneumonia) or inorganic(earings, wistle)
MC foreign body - peanuts and cornicks (hinahagis tapos
sasaluhin ng bibig)
ONSET
 Older infants and toddlers (< 5 y/o)
 Very common in toddlers or preschool <5 y/o
CAUSATIVE AGENT
CLINICAL FEATURES
 Highly suggestive: Cough and Wwheezing
 <Right main bronchus – common location; because wider
and straighter than Left> 3 stages of symptoms:
1. Violent paroxysms of coughing, choking, gagging and
possible airway obstruction – easy to dx if seen
2. Asymptomatic interval – delayed dx
3. Complications – obstruction, erosion, or infection
Fever, cough, hemoptysis, atelectasis
Once the foreign body is big enough to cause obstruction –
EMERGENCY
Clinical feature –depending on size
- Violent episodes of coughing, choking or gagging
- The body becomes used to it – became asymptomatic – this is a
potential problem because the physician will not push thru in
removing the foreign body
- Complication when not remove - recurrent pulmonary infection
DIAGNOSIS
 History
 Chest X-ray: If the object is lucent, not very helpful.
 CT scan: can be helpful to rule out
 Bronchoscopy: to investigate airways with a tube hooked to
AV monitor
BRONCHITIS
CAUSATIVE AGENT
 Viral: Parainfluenza and adenoviruses
o Adenovirus – most common pathogen causing
inflammation to the major bronchi
 Bacterial In infants (most common):
o H. influenzae
o S. pneumoniae
CLINICAL FEATURES
 Starts with rhinitis (URTI sx) -> eventually cough (starts as dry -
> eventually productive)
 Also vomiting - Young children do not know how to cough
out phlegm, so they swallow it
 Chest pain, or even abdominal pain - Older children, 2° to
excessive coughing and cough receptors
stretched/stimulated
Presents with ordinary cough and colds, may or may not have fever,
vomit as the way to get rid of their phlegm. Older children will
complain of chest pain or abdominal pain secondary to excessive
coughing but they will not have DOB. Sometimes the only
manifestation is cough. Bronchitis vs simple upper resp tract inf.
Upper resp inf - aside from the cough, usually meron pang iba. Like
colds and sore throat and fever
EVANGELISTA, FALCON, MARQUEZ, MIRASOL (3B)
If the object is lucent, not very helpful.
CT scan: can be helpful to rule out Bronchoscopy: to investigate
airways with a tube hooked to AV monitor
The child will not tell the parents because they are afraid that they
will be scolded. The only time that they will tell their parents is when
they experience discomfort and difficulty of breathing secondary to
the foreign body that is aspirated
Then request for an x-ray. Not all foreign bodies will be seen on the x-
ray. When the foreign body is radio lucent, you will not see it on the
xray. E.g. X-ray that shows a coin – in frontal view, you cannet tell if it
is in the esophagus or in the trachea, you need a lateral view xray.
in the xray, you will see that the right lung is darker than the left lung.
Therefore mas madami syang hangin. The foreign body is in the left
lung. All of the heart is in the left. The right lung is over inflated. This is
a case of a child who imitate the chippy commercial wherein they
will open it using their mouth. The small plastic particles can be
aspirated and we will not see it on x ray. When it lodges to the main
stem bronchus, it will not totally obstruct because it is small but it can
affect the inflow. The left lung begins to collapse.
CT scan is performed kapag walang Makita sa X-ray
MANAGEMENT
 Bronchoscopy
 Antibiotics – not routine unless organic FB
 Steroids – if long-standing and inflammation has set in
 Surgery – extreme cases, obj cannot be removed by scope
Bronchoscopy is performed kapag walang Makita sa x-ray or CT
scan. You can use a rigid or flexible. Inserted to the moth or one
nostril until you see the foreign body and it is corrected to a polymer,
makikita mo ang loob.
If the foreign body has been there for a long time, it is difficult to do
_______ (di ko maintindihan) eg. The pt came from Palawan with a
history of asthma for 5 years and x-ray was not performed. When he
came to manila we did an xray and it revealed that there is a screw
in the lung. The history revealed that the child is fond of
disassembling his toys. And because the screw has been there for 5
years, nagkaron na ng granulation doon, and when we try to pull it
with forcep, nagkakaroon ng bleeding. So we ended up by
operating the patient, and we open it up, the affected lung is
already necrotic so we remove the entire lung
Moral of the study, if in the vback of your mind foreign body is a
possibility, you should do all test to rule it out.
If the foreign body has been there for so long and you did a lot of
manipulation, you can give the pt antibiotic and steroids. If you still
cannot remove it, you must perform surgery.
Bronchitis – auscultation - can be normal/clear. As much as possible
ayaw natin ng harsh breath sounds. Some pts. Will have RONCHI
(characteristic of bronchitis)
Ronchi – produced due to the movement of secretions during
airflow.
Crackles – secretions are in the alveolus, during insp, it will dislodge
the secretions and it will produce a sound
Wheezing – secretions are in the airway that will narrow down the
lumen of the airway
DIAGNOSIS
 Auscultation often NORMAL -> but may present with
wheezing (d/t partial obstruction), crackles, and rhonchi
 Normal chest X-ray - In some cases there will be increased
bronchial markings (but this is not specific for bronchitis)
 It is benign – no resp distress
MANAGEMENT
 If Viral: Symptomatic and supportive tx, NO DOC, resolves
spontaneously 2 – 3 wks
 If Bacterial: DOC for H. influenzae: ampicillin DOC for S.
pneumoniae: penicillin
Supportive/symptomatic – virus
Misconception that the cough will resolve in 1 week. It should be
lessen after 1 week.
7
 BRONCHIOLITIS
CAUSATIVE AGENT
 RSV(most common pathogen), parainfluenza,
adenovirus, no evidence for bacterial cause
RSV - Respiratory Syncitial Virus / Human Orthopneumovirus
ONSET
 Infancy: 1-2 y/o; peak: 6-12 mos
 A disease of infancy
CLINICAL FEATURES
 Mild URTI: colds, dec appetite, fever
 TRIAD: tachypnea, chest retractions, wheezing (All 3 MUST
be present)
 The lumen of bronchioles are smaller than the bronchi,
when the airways become inflamed, there will be a
narrowing of lumen and it will produce a lot of secretions. So
the narrowed lumen will be filled with a lot of secretions. The
triad must be present in patient <2y/o. if the triad is present
in a 5y/o pt, you cannot dx him/her with bronchiolitis
 Wheezing - should rule out asthma
What are the chances that an infant will develop asthma
1. Family hx of asthma
2. Get nasal secretion – nasal smear – eosinophil – NASAL
EOSINOPHILIA
3. If responding to bronchodilator (nebulizer)
In some studies, a child who develop bronchiolitis, they will follow
up after 3 years to see if how many of them develop asthma
and it shows that 40% of the cases developed asthma. One
differentiating point nila is parental smoking
DIAGNOSIS
 Clinically diagnosed - no laboratory exams
 Chest Xray – for confirmation only
 Since there is wheezing, the most important differential
diagnosis would be ASTHMA (In asthma, there should be at
least 3 episodes of wheezing.)
 Chest radiography findings: Trapped air -> over-aerated
1) Flattening, imperfect dome diaphragm
2) Widened intercostal spaces
3) Some parts are hyperlucent, i.e, bases more
lucent than apices
History and PE is enough to establish the diagnosis of
bronchiolitis. In the event that you are not sure of the diagnosis,
you can get an x-ray.
x-ray
upright – air/gastric bubble (Magenblast) beneath the
left hemidiaphragm
supine – no air bubble
PA – v shape clavicle
AP - straight clavicle
PNEUMONIA
Diseases of the Respiratory System that you should master as a
general practitioner:
1. Common colds
2. Pneumonia
3. Asthma
4. TB
DESCRIPTION
 inflammation of the lung parenchyma, in some instances,
the airway is also involved but you cannot have a case in
which the lung parenchyma is not involved. Like any other
pulmonary disease, you should know the different
pathogens depending on the age groups
EVANGELISTA, FALCON, MARQUEZ, MIRASOL (3B)
 Look at the arms if it is raised – this will cause false impression
that the clavicle is v shape
- Compare the lungs, observe the lucency from apex to
base; on the sample x-ray film the base is more lucent than
the apices – basal air trapping.
- Normal diaphragm – perfect dome, if it is not, a sign of air
trapping . the lung is retaining more air so that it is pushing
down the diaphragm
- widened intercostals spaces
Radio review:
--- Supine film: if there is a a gap between diaphragm and
gastric gas bubble
--- Upright, PA film: v-shaped clavicle
MANAGEMENT
Treatment
 Upportive and symptomatic
 Mild cases are managed at home
 Mod to severe cases are hospitalized
Ribavirin – expensive & not routine part of mgmt
 Corticosteroids – to decrease inflammation
 Bronchodilators - for wheezing (But remember pathology is
not bronchoconstriction, so the result of this is not uniform
hence not part of routine management)
 Antibiotics – no role since viral
- Supportive. Mild cases can be treated at home, only those
who are severe, who are dehydrated or those who refuse to
feed must be admitted to the hospital
- Ribavirin – antiviral. Routine na naiibibigay sabi ni Nelson kasi
daw libre. Whether you give it or not, there will be no
difference
- Inflammation – steroids, however there are some patients
that are ______liform, some patients will have relieve after
administration of steroisds, some patients are not
- Bronchodilators – some patients improve, some are not.
Theoretically there is no bronchoconstriction. There is
nothing to dilate. But there are some cases that some
patients improved with nebulize bronchodilator
- Ribavirin, steroid, bronchodilator – not part of the standard
of care. You may or may not give it to your pt. you can try
or you can not at all
Prevention
 Alibizumab? – ab against the RSV protein – the problem is it
is expensive
- the patient must receive it every 2 months or every 2 weeks
- 1 vial costs 75k
- Usually you do not use it because the disease is benign
4 stages of Pneumonia
1. Congestion
2. Red
3. Gray
4. Resolution
Not all pts with pneumonia will undergo the 4 stages
If you are on the stage of hepatization, the lung parenchyma is
now filled with secretions.
Instead of air, secretions now occupy the alveoli.
Lungs become heavier, hard, assuming the consistency of a
liver.
In essence that would correspond to CONSOLIDATION and NOT
all pts with pneumonia would undergo consolidation.
8
CAUSATIVE AGENT
Neonate Most common pathogen is GBS Tx:
In the Philippines - E. coli and G (-) organism Ampicillin – to cover GBS
Aminoglycosides – E. coli (e.g Genta, Amikacin, Tobramycin)
Preschool 2 most common pathogen that would cause Note:
(2 to <5 yo) pneumonia in this age grp. Eg. Patient, 2 yo, has complete Hib vaccine, what organism to
1. H. influenza – suspect more if pt. is infant to 2yo consider?
2. Strep. pneumonia – more common if pt. is 2 to 5
yo Ans: Strep, even if 1 yo, as long as complete vaccination, NOT Hib.
Im not saying that it is impossible for you to have So, Strep pneumonia is the cause
pneumonia in a child who is 2-5 yo caused by H.
influenza. It is just more common in infant up to 2yo.
3. Staph aureus – 3rd organism to consider in this
age group but not as important as the 2
School Strep. pneumonia Walking Pneumonia
aged Grp Mycoplasma pneumoniae – aka ATYPICAL PNEUMONIA
(>6 yo) – child with full-blown Pneumonia, upon auscultation (+)
crackles, yet pt. seems to be comfortable, has no
difficulty of breathing and can still play
General Rule in pedia
– School age: Mycoplasma pneumonia  think if pt. is 6 yo
and above
– INFANT: Chlamydia pneumonia  think about this if <1 yo
UPDATE in JOURNAL
– Mycoplasma is not only confined to school-aged grp. It
was isolated even from infants
– Chlamydia also is now found even in older age groups

CLINICAL FEATURES
Clinical Features (Bacterial, Viral, Atypical) are more important in adults. Not so much in pedia.
However, in pedia, the clinical features overlap, there is no set of clinical feature that will strongly tell you with certainty if viral, bacterial.
However, features seen are MC in bacterial or viral pneumonia, so not all manifestations are referable to the RT
BACTERIAL PNEUMONIA
- sudden onset; fast clinical course
(mahihirapan agad huminga)
- Non-specific: fever, chills, headache,
irritability, GI problems
(Vomiting/Diarrhea)
Diarrhea – d/t the swallowed
phlegm capable of making stools -
softer, NOT watery
Vomit – if they don’t swallow their
phlegm, they vomit it (2 ways
how the child get rid of their
plegm)
Abdominal pain – referred pain
(R: Lungs and stomach share
some nervous supply.
Inflammation of the lung
parenchyma manifest also with
abdominal pain)
- High grade fever – bacterial cause
VIRAL PNEUMONIA
- Begins with URTI sx
- Gradual onset of respiratory
distress and cough (child is less
toxic looking vs. bacterial);
progressive symptoms (ilang araw
bago mahirapan huminga)
Crackles
- More appreciated w/viral:
 Wheezing – onset trying to
expire against a partially
closed glottis, usually in
neonates
 Grunting
- more appreciated in viral
pneumonia, usually seen in
infants (6months and below)
- Trying to expire against a
closed glottis, parang
umeere, everytime the child
breathes, you can hear it
- Very prominent in neonates
ATYPICAL PNEUMONIA
- Called atypical because they do not
follow the behavior of pneumonia
caused by TYPICAL pathogens
- Causative agents: Mycoplasma, Chlamydia
(50% of pneumonia caused by
Chlamydia: with (+) hx of conjunctivitis)
- Refractory to conventional antibiotics
- prolonged course and delayed resolution
- Drug of Choice: Macrolides
 1st gen – e.g. Erythromycin (NOT USED d/t
adv effect = GI upset)
 2nd gen – e.g Clarithromycin
 3rd gen – e.g. Azithromycin
- If refractory:
 Amoxicillin/Ampicillin
 2nd gen Cephalosporins
- X-ray Pattern: Interstitial Pneumonia – diffuse
pulmonary infiltrates
EXAMPLE:
Pt is 1 yo  think Haemophilus  DOC:
Ampicillin (R: Penicillin has NO coverage for
this)
You gave Ampiciilin for 1 week but not
improving
Think either resistance or might be d/t
secondary organism NOT responsive to your
DOC
So, from Ampicillin, now give Cephalosporin 
2nd gen – more gram negative coverage
Haemophilus is g (-)  give 2nd gen Ceph.
(Cefuroxime, Cefaclor)
If the pt. still did not improve, go to 3rd gen.
(Ceftriaxone, Beta lactamase resistant like Co-
Amoxiclav or Sulbactam)
Pag nakakita ng batang may Pneumonia, di
mo iisipin na atypical pneumonia agad, once
the drug does not work, that’s the time you will
realize that it is ATYPICAL

EVANGELISTA, FALCON, MARQUEZ, MIRASOL (3B) 9

 PULMONARY MANIFESTATIONS: EXTRAPULMONARY MANIFESTATIONS:
- Cough, always present in pneumonia EXCEPT in neonates - Altered sensorium drowsy (to determine, must be able to
- Pulmonary signs need not be present at the start interact with the patient)
- May have fever first or cold first before the COUGH - Hypoxemic -> drowsy
- Most important manifestation  COUGH (R: You cannot dx - Seizures (upward gaze, stunts)
pneumonia w/o cough except if the pt. is a neonate. In
neonate, cough is not so prominent) Can suggest etiologic organisms:
- >1 mo (+) cough - Skin infections (Strep, Staph) --- Maraming sugat sa paa  think
- Dyspnea, apnea, cyanosis, bradycardia of staph or strep, pt’s pneumonia might be d/t these organisms
 Dyspnea  DOB (intercostal retractions, - Ear infections – luga (Strep, H. influenza, Staph)
 Periodic respiration  cessation of breathing >20 seconds Eye infection + rash (measles)
 Apnea: cessation of breathing >20sec or episodic
breathing + cyanosis and bradycardia
- Use of accessory muscles of respiration (SCM, scalene,
trapezius)
- Tachypnea: most important clinical predictor of pneumonia
 Neonates – RR > 60 cpm
 1-12 mo – RR > 50cpm
 13 mo – 5yo – RR > 40cpm
 >5y/o – RR > 30cpm
DO A COMPLETE PE OF THE PATIENT
- Inspection
- Palpation
- Percussion: dullness (PE finding to differentiate fluid or gas, GAS
 heperresonant, NORMAL  resonant)
- Auscultation: crackles, ~diminished breath sounds
(all px with pneumonia present w/ crackles, except those
who are dehydrated)
- Retractions: Subcostal, supraclavicular, infraclavicular,
suprasternal retractions, intercostals
- VOCAL and TACTILE FREMITUS  differentiate solid from liquid
(SOLID  increased TF, FLUID  decreased)
- Chest pain  clue that there is pleural involvement
- Simple cases – chest pain is (-)
- Manifestations of respiratory problems need not be referable to
the respiratory tract, you can have manifestations involving
other systems (cardiac DOB results to compensatory
tachycardia, Inc. in VS)

Recurrent pneumonia Persistent/ Non resolving Microbiologic Studies:  to identify the pathogens
Pneumonia  Culture of lung aspirate – gold standard in the diagnosis of
– paulit ulit - persistence of bacterial pneumonia.
– At least 2 episodes in 1 symptoms and o R upper lobe  MC affected part of the lung
year radiologic o Get 10cc syringe, gauge 16 or 18
- In between, the x-ray would abnormalities >1 month o Count where’s the center rib
show clearing of the – In between, the x- o E.g rib no. 3, then mark
infiltrates ray DO NOT show o Puncture to aspirate secretions
- > 2 episodes in a year or > 3 clearing of the o Prob: very invasive, mothers won’t consent most of
episodes with radiologic infiltrates the time
clearing between  Blood cultures – low yield and may culture something else
occurrences mistakenly
o NOT routine bec:
DIAGNOSIS o the organism in the blood may not necessarily the
CAP Diagnosis organism causing the pneumonia of the patient
 History and clinical  hx of cough o low yield blood culture in pneumonia <15%
o Fever (+/-) o not routinely requested unless entertaining the
o PE: crackles, Tachypnea (based on WHO) possibility of SEPSIS
 Chest radiograph  not required especially if the patient is  Tracheal aspirates – intubation and section w/in 1hr o/w
NOT toxic looking or your very sure of the dx new colonization will set in
o Only if there are complications  solid, liquid or o via ET tube – through the nose/ mouth
gas o Impt: it will enter the trachea, suction the
o Determine severity secretions
o Unsure of dx  To confirm o Must be done within the 1st hr of intubation
 CBC - not need before giving antibiotics o R: >1 hr. intubated, there will be colonizers in the ET
o To determine ATYPICAL vs VIRAL tube, you might not get the exact pathogen
o Laboratory test to request is CBC causing the Pneumonia
o If lymphocytic predominance  VIRAL  Sputum culture and gram-stain – only for children >10 y/o
o Sometimes you may need >1 examination to give (capable of expectoration)
you the dx  Bacterial and viral antigen detection – kit, results in a few
o Correlate the results minutes, very expensive, done for research purposes
 ESR, CRP – acute phase reactants; no roles in pneumonia;  Tissue culture and viral antigen – gold standard for viral
not routinely requested pneumonia

EVANGELISTA, FALCON, MARQUEZ, MIRASOL (3B) 10

CAP MANAGEMENT CAP Complications
 Supportive Management  Pleural Effusion  liquid
 Continued feeding – unless high risk of infection  Pneumothorax  gas
o do not starve the pt. unless the risk for aspiration is
o Atelectasis  solid
very high
 Hydration
 Oxygen
 Antipyretics
 Clearing of nasal passages
 Chest physiotherapy  chest tapping/ clapping
o hand should be cupped, movement should be
from the wrist, do it fast
o if baby  use 1 or 2 fingers, put on the chest or
back, then vibrate
o to dislodge the secretions
o can also use the mask of the ambubag
o Percussor – device use by RTs
 Antibiotics

CAP PREVENTION
Classification based on the probability that the patient might die
 Proper prenatal care
d/t the PNEUMONIA
o poor prenatal care = low birth weight babies  risk
NOT classification of severity
factor for pneumonia mortality
Based on MORTALITY
 Immunization (Hib, DPT, TB, measles)
Don’t focus on the age
 Breast feeding
Important is Tachypneic
 Good Nutrition
 Vitamin A supplementation - promoting cell mediated
A vs B  A (-) co-morbidity and dehydration
immunity and enhance re-epithelialization of airway
B vs C  C greater signs of dehydration, other signs of respi
 Reduction of pollution and crowding  to prevent spread
distress (retractions)
of infx
C vs D  D sensorial changes, abN sounds, complications
o ZINC  for prevention of pneumonia (NOT
A and B  can be managed OPD
treatment)
C  admitted – WARD
D  admitted – ICU
MC cause of Pneumonia in the Phils  MIXED (give antibiotics)
In the US  d/t viruses (They do not routinely start antibiotics)

LOBAR PNEUMONIA/ BRONCHOPNEUMONIA INTERSTITIAL PNEUMONIA

LOBAR CONSOLIDATION
 Opacity in the R upper lobe  Strep, haemophilus, staph, gram (-)  think viral or atypical pathogens
 Filled with secretions   With INFILTRATES described as to:  INFILTRATES
CONSOLIDATION 1. Describe (Fine or Course)  Course 1. Fine  bec. The secretions are
 Think or Haemophilus or Strep (NOT virus  bec. The secretions are inside outside the alveolus (interstitial
nor atypical) the alveolus spaces)
2. Location  Diffuse
 With predilection for the hilar area
 Alveolus  Acinus lobule lobe
 The air went to the alveoli, from1
alveolus it went to the surrounding
alveoli
 This is d/t the communications between
the alveoli  Pores of Kohn and Canals
of Lambert
 1 organism transfers from 1 alveoli to
the other  passes through the airway,
eventually invade the surrounding lung
parenchyma
 = Airway and parenchymal
involvement

EVANGELISTA, FALCON, MARQUEZ, MIRASOL (3B) 11

 PLEURAL EFFUSION
DESCRIPTION
 Pleural fluid is found bet parietal and visceral pleura
 Normally 1-2ml per hemi thorax -> prevents adherence of
visceral to parietal pleura
 Excess pleural fluid inside the thoracic cavity
Pleural fluid in the fluid cavity  N (At least 4 -12 ml)
Old books: 1-2 ml

ETIOLOGY
 90% of PF filtered out of arterial end is reabsorbed at venous
end
 <10% return to lymphatics Sometimes the Xray result is not classic Pleural Effusion
 Starling’s Law = balance between filtration and absorption Still wondering if fluid or solid
Hydrostatic and oncotic Request for thoracic UTZ to differentiate
Normal: Hydrostatic pressure > oncotic pressure  net
effect: more fluid outside the blood vessels 3) Ultrasonography
but the difference must be small to maintain the 4-12ml 4) Thoracentesis - Insert a plastic needle with a stylet and
 Causes – d/t Pneumonia or secondary to other diseases (TB, aspirate fluid in the chest, submit for analysis
renal, cardiac problems) o Clear/yellow – serous
o Purulent – pus,“nana”
CLINICAL FEATURES o Sanguinous, blood – hemothorax
 With history of cough, tachypnea

DIAGNOSIS
1) Hx and PE findings:
o Auscultation: ↓breath sounds since H2O is not a good
Transudates - inflammatory Exudates - infection
conductor of sound, ~retractions
condition
o breath sounds decreased  (decreased BS are d/t
 Occurs with intact  Results from
solid, liquid or gas, that is why you must have a
capillaries inflammation – as in
complete PE to identify what is inside)
 Proteins do not leak pneumonia
o Percussion – to differentiate fluid (dull) vs other causes
through  Protein-rich fluid leaks
o Fremitus – decreased
 ↑Hydrostatic pressure or from capillaries
o Retractions - +/- depending on the volume (small
decreased oncotic  Local causes
amount of fluid = no retractions)
pressure
2) X-ray
 Systemic causes - CHF,
o Necessary and always upright position
kidney dse, tb
(Magenblaze/gas bubble found immediately below
the left hemidiaphragm)
o Demonstrate air fluid level  meniscus sign 
diagnostic of Pleural Eff.
o Costophrenic Angle – angle form by ribs and
diaphragm, normally sharp, but in effusion disappears,
blunting or loss because it is filled with fluid Rationale: knowing whether exudate or trasudate, to
o Intercostal spaces  widen depending on the volume identify possible etiology
of the fluid 5) Microbiologic Studies (underlying cause)
o LLD can also be done – allows you to see air fluid level,  Gram stain
even measureable -> Meniscus Sign (Significant is  Culture
>1cm)  AFB smear (not routine in US, routine in the Phils)
 mortal sin thoracentesis but did not get an AFB
smear
MANAGEMENT
SEROUS: PURULENT (NANA): SURGERY
Antibiotics based on age of patient  Presumed Staph, unless proven  Decortication operate the child,
 If pt. did not had Hib vaccine  otherwise  Oxacillin open the chest, peel off the hard pus,
give Ampicillin o If MRSA, Resistant  major procedure, very bloody
 If pt. had Hib vaccine expect Vancomycin, but expensive  VATS - Video assisted thoracoscopy 
Strep.  Give Penicillin o Anti-staphylococcal drugs no need to open the chest wall, just
 Infant – H. influenzae -> ampicillin  Tube drainage/closed-tube make a hole then insert a tube with
 Preschool+ - S. pneumoniae until thoracostomy (decide if the fluid should video to see the chest cavity, then
proven otherwise -> penicillin be drained) operate
 Also look at immunization status Indicated if fulfills one of the In thoracostomy, when you hit the bone,
following: need only 1 of the 5 slide the needle UP to prevent hitting the
o Gross pus vein artery and nerve
o Serous, do gram stain  Evacuate the pus  If the pus is left inside
(+) Microorganism on GS the chest antibiotic won’t be able to take
If fulfills neither, wait for effect the pus will harden
chemical analysis:  Prevent the lungs from expanding
o PF glucose <40 mg/dL  Patient will become dyspneic
o PF LDH >1000 IU (restrictive lung)
o PF pH <7.0
If not purulent, wait for analysis

EVANGELISTA, FALCON, MARQUEZ, MIRASOL (3B) 12

 TB EFFUSION HEMOTHORAX CHYLOTHORAX
If it is purulent, you can call it empyema or PF hematocrit >50% milky, white or yellow, no smell
pyothorax  From the thoracic duct, w/c can be
Char feature: TB effusion: PF protein >5g/dL injured by surgery
(If it coagulates on standing -> it is simply In neonates – most common cause of PF
traumatic; you hit the VAN of the ribs) PF triglycerides >110mg/dL
-> ratio >0.5 -> true Smear: demonstration of fat globules,
hemothorax chylomicrons

PNEUMOTHORAX
DESCRIPTION
 Inside the thoracic cavity, usually there is no free air Usually
it is in the alveoli and bronchus.
 Abnormal accumulation of gas in the pleural cavity
CAUSATIVE AGENT
 Mostly consist of Nitrogen, O2 only 20%
 Adult - the common cause is stab/trauma (Never remove
weapon to prevent air from rushing in d/t pressure gradient,
suck in of atmospheric air)
 In pediatrics - the most common is still infection (Pneumonia)
 Alveolar rupture
CLINICAL FEATURES
Types:
1. Primary spontaneous – “kusang nangyayari” no traumatic,
or underlying disease ,
Typical pt: M, adolescent, asthenic, athletic
Usual scenario: Chest pain collapse (rupture of lung)
2. Secondary spontaneous – in gen. practice MC, d/t
underlying lung dse but NO trauma
3. Traumatic
4. Iatrogenic - 2° to procedure, careless procedure
5. Catamenial – blebs or diaphragmatic defects
Typical pt: F, adolescent, during their monthly pd
 - Fill kidney basin with water, opposite end of butterfly needle in
- because air moves more quickly as compared to fluids
Mabilis dumami ang air compared sa fluids
- px complains of SUDDEN DYSPNEA AND CHEST PAIN
Hx of Pneumothorax: acute tachypnea, acute resp distress
Hx of Pleural Effusion: progressive tachypnea, progressive resp
distress
- severity of symptoms will depend on extent of lung collapsed
and pre-existing lung disease
DIAGNOSIS
History and PE – Diagnostic: hyperresonant lung fields
Confirm by X-ray XRAY!!!
- Hyperlucent = matches background lucency, blackness
- Absence of lung markings (pathognomonic)
 ibig sabihin hangin lng eto outside of the lungs
Heart moves to the right meaning there is something occupying
the left side
MANAGEMENT
1. If Mild - give 100% oxygen (Green tank –100% O2; Black/
Gray tank – 21% O2/room air/ compressed air)
-how would you know it is minimal, check the xray, there is a
computation for this.
if pt’s face mask nakasabit sa green tank, receive not exactly
100% not unless the tube of the tank is connected to the trachea
itself. It will be diluted by the room air.
Actual conc of O2 received is actually FiO2/ fraction of inspired
oxygen.
No. of %O2 labeled on the tank- it is the actually the FiO2
received by the pt
Most abundant gas in room air is nitrogen.
- Principle of denitrogenation or nitrogen wash up – 100% oxygen
readily displaces nitrogen o In PT air is usu nitrogen so if given O2
it will eventually replace it and it will be absorbed by blood
only done in mild pneumothorax
2. If massive –
a. chest tube thoracostomy
- Usually done by surgeon
-insert a chest tube to remove all of the air out
Where to place the tube on the chest: fluid- down; air-up
if you haven’t seen the x-ray of the pt , do not attempt to
thoracentesis. Confirm first the location
b. Direct needle aspiration (needling)–emergency
procedure
water
- Per x-ray place needle, air will be drawn out bubble
formation
- Emergency relief only, until surgeon available
c. Chemical pleurodesis
- Recurrent pneumothorax
- chest tube insertion w/ sclerosing agent = talc powder
Talc will insite sclerosis/ fibrosis so that the leak will be covered up

EVANGELISTA, FALCON, MARQUEZ, MIRASOL (3B) 13

 ATELECTASIS
DESCRIPTION
 lungs collapse or not properly expanded
 Imperfect expansion/collapse of a segment or lobe of a
lung

ETIOLOGY
1. External pressure
a. External compression w/in thoracic cavity– effusion,
enlarged LN, tumor causes impingment  collapse
b. Direct interference w/ expansion
2. Intrabronchial (airway) obstruction - MC
a. Most important
b. Usu mucus plug- MC  secretions
3. Reduced amplitude of expansion
a. Common in surgery pts
b. Shallow breathing -> lung collapse
usually advice the pt to deep breath  Wedge or fan shaped - typical finding
because it is painful to breathe, the pt will tend to do shallow - Triangular Shape/Wedge Shape/Fan Shape/ Pyramidal of
breathing instead opacity
- Apex is in middle part
PATHOPHYSIOLOGY - Only atelectasis causes shift (trachea, etc.) to the same side, all
- Incomplete: air passes in but cannot be expired other chest lesions push it opposite (by palpation, you can also
- Complete: air cannot even pass in appreciate tracheal deviation to the ipsilateral side of the lesion)
If there is an obstruction in the airway, whch will collapse - Asymmetrical lung expansion, lag on right o PMI deviated to
proximal or distal? distal right
 Nitrogen - absorbed in 2-3h
 O2 – absorbed = 6-10 mins MANAGEMENT
 Eventually nitrogen will be absorbed + obstruction (no new - Depends on cause, duration and severity
air) -> atelectasis - Antibiotics – pneumonia secretions
- Occluded airway -> trapped air - Bronchodilator – asthma
The more segments of the lung that is occluded, the more - Bronchoscopy –remove FB (critical period – 8 weeks)
symptoms the patient will present -> fibrotic or necrotic lungs
 All distal to occluded airway will be collapsed
hospital
CLINICAL FEATURES AND DIAGNOSIS
for another
 PE findings similar to Consolidation x-ray
- Parenchyma compressed together, solidified - Chest physiotherapy- secretions
- RLL and LLL most frequently collapsed - Corticosteroids – asthma
- But in pts w/ PTB, RML are the ones usually collapsed - Tb – anti-tb drugs
 Chest X-ray
-establish the diagnosis PROGNOSIS
 Horizontal fissure –division separating RUL and RML
- Benign
- Normal - forms right angle w/ vertebral column
- Prone to infection if remains to become atelectatic
CONSOLIDATION ATELECTASIS - If persistent -> bronchiectasis, lung abscess
Lung the lung is filled with the lung is reduced
appearance secretions in size because of no
air
Angle of lungs filled w/mucous less volume,
Horizontal and secretions -> becomes smaller,
fissure ↑volume -> more acute angle
increased/obtuse or
same angle

EVANGELISTA, FALCON, MARQUEZ, MIRASOL (3B) 14

 SAMPLE CASES
A 9 mo old infant bought to the opd with a hx of 1 day
productive cough, watery nasal discharge, low to moderate
grade fever. On the day of consultation the infant is breathing
fast, hence he brought to the ER.
1. Where is the pathology? Upper or lower RT?
Lower –the patient is presenting difficulty of breathing
Upper – will not present with respiratory distress, they
are benign
Any problem invoving the larynx, there is
hoarseness of voice, signs of obstruction – stridor
2. Airways or lung parenchyma?
Airway – very acute. 1 day hx of cough then progress
to DOB. Very fast, very short, nahirapan huminga, think
of airway problem
Parenchymal – 2 lungs; pneumonia - coughing for few
days before DOB
DIAGNOSIS:
Bronchiolitis – age- 9 mos, tachypnic, retractions.
But if I will give you a case in which the pt’s RR is 62bpm,
symmetrical chest expansion, intercostals retraction, crackles
and wheezes on both lung fields. Pat medical history had 2
similar episodes at 3 months and 5 months of age. What would
be your diagnosis – bronchial asthma
Cannot be bronchitis – because bronchitis is a benign
condition. You are not suppose to manifest respiratory
distress.
2 benign diseases
1. Bronchitis
2. Laryngitis
EVANGELISTA, FALCON, MARQUEZ, MIRASOL (3B)
5 y.o. boy brought to the ER because of DOB. Productive cough
for 1 week, high grade fever for 2 days. On PE, the RR was 50, he
had symmetrical chest expansion, intercostal retractions
bilateral, decreased breath sounds on the right, decreased
vocal and tactile fremitus on the right, dull percussion.
What condition should we consider? Pleural Effusion
What is your next step? X-ray to confirm the presence of pleural
effusion.
What if there is a homogenous opacity on the right the heart is
midline the entire right lung. Is it a clear case of pleural effusion?
No coz of the normal position of the heart. In pleural effusion,
heart should deviate to the opposite side.
UTZ should be done  to differentiate if solid or liquid
A 5 y.o. boy was admitted to the hospital due to respiratory
distress. X-ray coarse infiltrates on both fields. The patient was
started on IV pen. After 3 days, the patient’s condition was
improved. He was more comfortable at room air, was eating
and was just waiting for the completion of medicines. On the 6th
hospital day, he suddenly complained of dyspnea and was
noted to be irritable.
What condition should we consider? Pneumothorax
The patient was stable or previously well then suddenly dyspneic,
if the patient can verbalize will complain of chest pain 
pneumothorax  chest xray
Happy happy birthday Nikko Jay and Hannah!! <3
15