דלקות ריאה חוזרותדלקות ריאה חוזרותדר. דוד שוסיוב

היחידה למחלות ריאה בילדיםבית חולים הדסה ירושלים

חשוב*

בבחינה!

DefinitionDefinition

Recurrent pneumonia is defined as at least 2 pneumonia episodes in a 1-year period or at least 3 during a lifetime.

חשוב*

בבחינה!

Recurrent Pneumonia

Recurrent pneumonia constitutes a threat to the integrity and normal development of the respiratory system

Every possible effort should be performed to make the correct diagnosis and treatment

Recurrent Pneumonia localized

foreign body aspiration congenital anomalies asthma mucoid impaction

diffuse Cystic Fibrosis (CF) Immunodeficiency Primary Ciliary Dyskinesia (PCD) Aspiration syndromes Vasculitis

*

חשוב*

בבחינה!

Recurrent Pneumonia localized

foreign body aspiration congenital anomalies asthma mucoid impaction

Foreign Body Aspiration in Foreign Body Aspiration in ChildrenChildren

Aspiration of a foreign body to the airway can endanger life immediately, or in the long term due to chronic lung infection and bronchiectasis

the main goals of the treatment of foreign bodies are:

◦prevention

◦early diagnosis

◦ Intervention

Foreign Body Aspiration in Foreign Body Aspiration in ChildrenChildrenThe diagnosis is some times very difficult

as there is often no:

◦ leading history

◦typical physical examination

◦radiographic findings.

*

Rigid BronchoscopyRigid Bronchoscopy

Foreign Body Aspiration in Foreign Body Aspiration in ChildrenChildren

8 months old infant developed a sudden cough while crawling on the floor.

examination revealed diminished breath sounds over the right lung

Foreign Body Aspiration in Foreign Body Aspiration in ChildrenChildren

A 14 months old girl choked during eating chicken soup

on examination she was tachypneic and dispneic. breaths sounds were normal over both lungs

chest radiograph was normal

fluoroscopy was interpreted as normal

Due to her critical condition, rigid bronchoscopy was performed demonstrating a hollow chicken bone in the left main bronchus

Foreign Body Aspiration in Children

Foreign Body Aspiration in Foreign Body Aspiration in ChildrenChildren

Revision of the fluoroscopy film revealed the chicken bone located in the left main bronchus

Foreign Body Aspiration in Foreign Body Aspiration in ChildrenChildrenA 3 year old girl was transferred from

another hospital due to a severe asthma attack which did not respond to high doses of IV steroids and inhaled bronchodilators

Examination revealed normal breaths sound while lying supine, however in the seating position she developed severe respiratory distress

Foreign Body Aspiration in Foreign Body Aspiration in ChildrenChildren Rigid

bronchoscopy demonstrated a swollen watermelon seed sliding along the trachea

Inflammatory pseudo-polypInflammatory pseudo-polyp

A 3 years old boy was referred to evaluate recurrent RLL pneumonia

Bronchoscopy revealed a polypoid mass obstructing the Rt. main bronchus

Inflammatory pseudo-polypInflammatory pseudo-polyp

After removing the polypoid mass, a small piece of almond was seen

Rigid bronchoscopies performed Rigid bronchoscopies performed for suspected foreign body for suspected foreign body aspiration in children - aspiration in children - results of results of 173 procedures173 procedures

FB (+) FB (-)

male 80 (66%) 32 (61%)

female 41 (34%) 20 (39%)

total 121 (70%) 52 (30%)

Rigid bronchoscopies performed for Rigid bronchoscopies performed for suspected foreign body aspiration in suspected foreign body aspiration in childrenchildren

Age (yr)

%

0-1 12 1-2 57 2-3 12 3-4 4 >4 13

location %

right 49

left 33

bilateral 8

trachea 7

larynx 3

*

Rigid bronchoscopies performed for Rigid bronchoscopies performed for suspected foreign body aspiration in suspected foreign body aspiration in children - children - historyhistory

FB (+) FB (-) p

Sudden choking 69% 37% <0.01

Sudden tachypnea 36% 10% <0.01

Rigid bronchoscopies performed Rigid bronchoscopies performed for suspected foreign body for suspected foreign body aspiration aspiration physical examinationphysical examination

FB (+) FB (-) p

diminished air entry

75% 59% <0.01

wheezing 45% 23% <0.05

crepitations 22% 42% <0.05

Rigid bronchoscopies performed for Rigid bronchoscopies performed for suspected foreign body aspiration in suspected foreign body aspiration in children children - - Chest X rayChest X ray

FB (+) FB (-) p

hyperinflation 51% 17% <0.01

atelectasis 14% 8% ns

infiltrate 32% 58% <0.01

Rigid bronchoscopies performed for Rigid bronchoscopies performed for suspected foreign body aspiration in suspected foreign body aspiration in children children --Yield of 86 fluoroscopiesYield of 86 fluoroscopies

FB (+) FB (-)

fluoroscopy (+) 41.0% 5.8%

fluoroscopy (-) 30.0% 22.0%

P=0.034

Indications for Bronchoscopy for Indications for Bronchoscopy for Suspected Foreign AspirationSuspected Foreign Aspiration

The prediction of foreign body aspiration is best achieved by:

1. history 2. physical examination 3. chest radiography

*

Recurrent Pneumonia

localizedforeign body aspiration

congenital anomalies asthmamucoid impaction

Recurrent PneumoniaRecurrent PneumoniaCongenital anomaliesCongenital anomalies

distorted structure

◦sequestration◦cystic adenomatoid malformation (CCAM)

airway obstruction

StenosisMalaciaexternal compressionvascular rings, slingscysts

Cong Cystic Adenomatoid Malformation - CCAM

Pulmonary sequestrationAngiography with systemic circulation

Bronchomalacia - LMB

Bronchomalacia - LMB

Bronchomalacia - LMB

Bronchial stenosis

Normal aortic arch ?

Double aortic arch

Recurrent Pneumonia

localized foreign body aspirationcongenital anomalies

asthmamucoid impaction

AsthmaRight middle lobe syndrome

* !

Recurrent Pneumonia

localized foreign body aspirationcongenital anomalies asthma

mucoid impaction

Mucoid impaction:bronchial casteosinophilsdehydrated secertions

Associated with:Post heart surgery *cystic fibrosisasthmaallergic bronchopulmonary aspergillosis (ABPA)

Recurrent Pneumonia

diffuse cystic fibrosis immunodeficiencies primary ciliary dyskinesia aspiration syndromes

Recurrent Pneumonia

diffuse cystic fibrosis immunodeficiencies primary ciliary dyskinesia aspiration syndromes

ImmunodeficienciesImmunodeficienciesAgammaglobulinemia - x linked

IgG subclass deficiency

Complement deficiency

Neutrophil abnormalities:

◦Schwachman-Diamond syndrome◦Chronic granulomatous diseae (CGD)◦Chediac-Higashi syndrome◦Job’s syndrome (תסמונת איוב)◦cyclic neutropenia◦drug induced neutropenia

Recurrent Pneumonia

diffuse cystic fibrosis immunodeficiencies

primary ciliary dyskinesia

(PCD) !! aspiration syndromes

Primary ciliary dyskinesiaPrimary ciliary dyskinesia

chronic sinusitischronic and rec. otitis mediarecurrent pneumonia & bronchiectasis

situs inversus (50%)male infertility (50%)Females some problemsLow Nasal Nitric Oxide (NO)

PCDmaxillary sinusitis

PCDmaxillary sinusitis

Normal cilium

PCD

PCDdysorientation of central tubules

Recurrent Pneumonia

diffuse cystic fibrosis immunodeficiencies primary ciliary dyskinesia

aspiration syndromes

from above secondary toGE-reflux

aspiration

Aspiration from aboveAspiration from above

choanal stenosis cleft palate

macroglossia laryngotracheal cleft

micrognathia TEF-H type

vascular ring

congenital anomalies

Tracheo-esophageal fistula

Aspiration from aboveAspiration from above

b irth asp h yxia fam ilia l d ysau ton om ia

cereb ra l p a lsy m yop ath ies

voca l co rd p ara lys is sp in a l m u scu la r a trop h y

n eu rom u scu la r d iso rd ers

Familial Familial Dysautonomia (FD)Dysautonomia (FD)Riley-Day SyndromeRiley-Day Syndrome

Aspiration◦Eating and drinking◦GE reflux and vomiting

(FD crisis)

◦Dysautonomia- Fever, high and low blood pressure etc.

Case Presentation ,CPCase Presentation ,CPaspiration from aboveaspiration from above

Case Presentation ,CPCase Presentation ,CPaspiration from aboveaspiration from above

from above secondary toGE-reflux

aspiration

Gastro-Esophageal Reflux and Gastro-Esophageal Reflux and AspirationAspiration

one of the major causes for lung disease in infants and children

diagnosis is often delayed due to:◦unawareness◦low sensitivity and specificity of diagnostic

procedures

Gastro-Esophageal Reflux Gastro-Esophageal Reflux Disease (GERD)Disease (GERD)symptomssymptoms

respiratorychronic coughwheezingrecurrent pneumoniaapneastridorhoarseness

gastrointestinalVomitingirritabilitydysphagiaanemiafailure to thrive

Gastro-Esophageal RefluxGastro-Esophageal Refluxbarium swallowbarium swallow

Gastro-Esophageal RefluxGastro-Esophageal Reflux 24 hr esophageal pH monitoring24 hr esophageal pH monitoring

Gastric scintigram (milk scan)Gastric scintigram (milk scan)

Recurrent PneumoniaRecurrent Pneumoniadiagnosisdiagnosis

historyphysical

findings◦clubbing◦burrel chest◦cracels

Chest x-rayBronchoscopyHRCTBronchography (?)Sweat TestImmunoglobulinsIgEPFT with challengeNitric Oxide (exhaled

and Nasal)

•Arterial Blood Gas•SaO2

* ! ?

* !Clubbing - התאלות

Recurrent pneumonia LLLRecurrent pneumonia LLL

Bronchiectasis - CT

Bronchiectasis - bronchography

Flexible bronchoscopy

Rigid bronchoscopy

PCP CMV

Aspergillus fumigatus mucor

Cndida albicans

BAL – lipid laden alveolar macrophages

*

BAL – Hemosiderin laden macrophages

* !* ! Pulmonary hemorrhage Pulmonary Hemosiderosis

Primary and seconday Hypoxia Crackles (crepitation) Pulm Infiltration in CXR

(ground glass appearance) Decreased Hb during

exacerbations Higher DLCO in PFT

Charcoal tracheal

instillation

Polystyrene microspheres in alveolar macrophages af ter tracheal instillation in hamsters

Recurrent pneumoniaRecurrent pneumoniatreatmenttreatment

Identify and treat primary causePhysiotherapy and postural drainageHypertonic Saline Inhalation – to

increase mucociliary clearanceDNAase inhalation (Pulmozyme)Antibiotics (PO, IV, Inhalations)Surgery

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