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Q/3 A 4-year-old presented with an acute attack of asthma and subsequently developed respiratory distress. Upon examination, one side of the chest exhibits significantly reduced breath sounds, hyper resonance upon percussion, with the trachea and heart shifting toward the unaffected side. Which of the following complications is most likely?

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Why not acute bronchiolitis? acute bronchiolitis mostly present with low grade fever (less than 38,5) In addition to the scattered rhonchi which suggests pneumonia rather than bronchiolitis ( present with wheezy chest ) Mycoplasma pneumonia typically presents in older children and it’s present as atypical pneumonia Walking pneumonia مثل ما اتفقنا Viral pneumonia = diffuse crackles and low grade fever So answer is bacterial pneumonia

Q2/ An 11-month-old girl was complaining high-grade fever, reluctant to feed, cough for one day. She looks ill, temperature was 40° C, RR 60 cycle /min. there is scattered rhonchi and crackle over the right side of her chest on auscultation. What is the likely diagnosis?

A 6-year-old boy had history of recurrent chest infections over last 3 years, last week he was presented with purulent cough o copious sputum mainly at morning, on examination he had finger clubbing and auscultation of the chest there was bilateral diffuse coarse crackle.

وزاري Respiratory 🆘👇🏻👇🏻

🟡 Pneumothorax – Golden Keys 🔑 Key Symptoms • Sudden onset dyspnea • Sudden sharp pleuritic chest pain • Often after coughing / crying / trauma (خصوصًا عند الأطفال) ⸻ 🔑 Key Signs • Unilateral ↓ breath sounds • Hyper-resonant percussion • ↓ chest expansion on affected side • Tachypnea + tachycardia ⸻ 🔑 Red Flags (Tension Pneumothorax) • Severe respiratory distress • Hypotension • Tracheal deviation away from affected side • Distended neck veins • Cyanosis 👉 Diagnosis is clinical — don’t wait for X-ray ⸻ 🔑 X-ray Keys • Absent lung markings • Visible pleural line • Collapsed lung • In tension: mediastinal shift شوكت افكر بيها ؟؟ Sudden onset dyspnea عند طفل اصلا عنده مشكلة وحسب العمر 🔑 Age / Cause Keys • Neonate: RDS, meconium aspiration خصوصا ادا جان على Positive Pressure Ventilation (PPV) ممكن تسبباه بارترومت وادخله بنيموثوراكس • Child: Asthma, bronchiolitis (air trapping) • Adolescent: Tall thin male (primary spontaneous) • Trauma: Secondary pneumothorax ممكن مثلا Rx :

PNEUMONIA FEVER 🔑, PRODUCTIVE COUGH 🔑, TACHYPNEA 🔑 Pneumonia is an inflammation of the lung parenchyma due to infectious or non-infectious causes. Pneumonia & Diarrhea are the most common cause of death in children worldwide. Absence of clinical signs and normal CXR makes pneumonia unlikely Up to 35% of lower respiratory tract infections have single virus as causative organism Can be presenting illness in cystic fibrosis and immunodeficiency states Symptoms:- Typical pneumonia = Fever + Cough (short, painful and dry at first then become productive) + TACHYPNEA Constitutional symptoms Sputum is purulent Lower lobes (basal) pneumonia may cause upper abdominal pain Poor feeding Vomiting Tachypnoea at rest (most useful sign) Atypical pneumonia (((( WALKING pneumonia 🚶 )))) 🔑 ليش اسمها “Walking”؟ لأن الطفل: • يمشي •شكله مو toxic Often caused by mycoplasma or chlamydia pneumoniainfections. • Low-grade fever • Dry cough (persistent) • Mild dyspnea • Headache / malaise • Child looks well بشكل عام ، شنو اشوف بالاكزام ؟ Chest examination may reveal : diminished breath sounds with scattered rhonchi , crackles in early stages. In later stage there may be : consolidation dullness on percussion further diminished breath sounds. Table 1: WHO definition of tachypnoea <2 months - 60/min 2–11 months - 50/min 1–5 yr-40/min Severe pneumonia ≥2 of following: temp >38.5°C respiratory rate >50 (>70 infant) cyanosis tachycardia, capillary refill time >2 sec signs of dehydration severe recession not feeding apnoea difficulty breathing flaring grunting Investigations: Chest radiography If severe pneumonia: blood culture Serum electrolytes (may have hyponatraemia owing to SIADH), Pleural fluid culture and pneumococcal PCR if aspirated pneumococcal antigen in urine Culture The definitive diagnosis of a bacterial infection isolation from the blood (≤10% with bacterial pneumonia), the pleural fluid (60-85%) Cold agglutinin in mycoplasma pneumonia is found in 50% of cases Autoimmune haemolytic anemia + Pneumonia = MYCOPLASMA PNEUMONIA ASO group A streptococcus pneumonia. PCR for M. pneumonia. It can be divided according to the age of presentation as following 🔑🔑🔑🔑 🔑 Pneumonia by Age – GOLDEN KEYS ⸻ 👶 Neonate (< 2 months) Think: Sepsis pneumonia Keys 🔑 • Poor feeding • Apnea • Hypothermia / Fever • No cough Common organisms • GBS • E. coli • Klebsiella Tx 🔑 ➡️ Ampicillin + Gentamicin ⸻ 👶 2 months – 5 years Think: Mostly Viral Keys 🔑 • Wheeze • Coryza • Low-grade fever • Diffuse crackles Common organisms • RSV • Influenza • Parainfluenza Tx 🔑 ➡️ Supportive (O₂ – fluids – antipyretic) ❌ No routine antibiotics 📌 If bacterial suspected: ➡️ Amoxicillin ⸻ 🧒 > 5 years (School age) Think: Walking (Atypical) pneumonia Keys 🔑 • Dry cough (persistent) • Low fever • Headache • Child looks well Common organism • Mycoplasma pneumoniae Tx 🔑 ➡️ Macrolide (Azithromycin) ⸻ 🚨 Any age + Severe / Toxic Think: Typical bacterial Keys 🔑 • High fever • Toxic look • Chest indrawing • Focal crepitations Common organism • Strep. pneumoniae Tx 🔑 ➡️ IV Ampicillin / Ceftriaxone Indications of hospitalization include: age <6 mo severe respiratory distress toxic appearance requirement for supplemental oxygen vomiting & dehydration multiple lobe involvement on CXR, immunodeficiency pre-existing pulmonary or cardiac disease no response to home therapy with oral antibiotics, & noncompliant parents. For hospitalized patient give oxygen, hydration, & parenteral antibiotics e.g. Cefotaxime or Ceftriaxone. If staphylococcal pneumonia is suspected 🔑🔑 Vancomycin or Clindamycin.

Acute asthma Asthma exacerbations are acute or subacute episodes of progressively worsening symptoms and airflow obstruction. Airflow obstruction during exacerbations can become extensive, resulting in life-threatening respiratory insufficiency. Clinical presentation according to severity Mild / moderate SEVER LIFE THREATENING 🆘 (See photo below) Patients with severe or life-threatening attacks may not be distressed and may not have all these abnormalities. Presence of any one of these should alert doctor Differential diagnosis Inhaled foreign body Pneumonia Pneumothorax  Aspiration Tracheobronchomalacia Gastro-oesophageal reflux How to assess? Record: respiratory rate and effort , recession , heart rate , air entry , oxygen saturation in air , if ≥5 yr, PEF ,conscious level CXR if severe and life-threatening sign/symptoms do not IMPROVE with medical management Routine CXR is unnecessary in child with asthma. Diagnosis is clinical. Only perform blood gas if it is likely to change management RX Rx. Patient is better managed in the ICU cardiorespiratory monitoring with the following Rx:- 1. Oxygen therapy (maintain O 2 saturation >92%). 2. Inhaled SABA (can be repeated every 20 min). with continuous 3. Systemic corticosteroids as short-course (orally or parentrally). If the above Rx fails to control the attack, consider the following:- 4. Inhaled Ipratropium bromide (usually mixed with SABA). 5. Adrenalin SC or IM (0.01 mg/kg). 6. Terbutaline infusion (with cardiorespiratory monitoring). 7. Other medications e.g. Aminophylline infusion, MgSO4 , or Heliox. 8. Mechanical ventilation for extreme cases with impending respiratory failure, especially when the patient develop Hopkins syndrome, a rare synd due to idiopathic asthma-associated flaccid paralysis. Monitoring If treated with IV bronchodilator therapies: Record heart rate and respiratory rate every 15‒30 min until patient stabilised Continuous SpO 2 monitoring Continuous cardiac monitoring Baseline U&E Capillary blood gas and lactate Regular capillary gas for electrolyte and lactate (at least 12-hrly) DISCHARGE AND FOLLOW-UP Discharge criteria SpO 2 in air ≥94% Respiratory rate: aged <5 yr: <40 breaths/min , aged 5–11 yr: <30 breaths/min , aged 12–18 yr: <25 breaths/min Heart rate: aged <5 yr: <140 beats/min ,aged 5–11 yr: <125 beats/min , aged 12–18 yr: <110 beats/min Peak flow: ≥75% predicted/best (aged >5 yr) Stable on 4-hrly treatment Discharge home if: Child has made significant improvement and has remained stable for 4 hr Parents: understand use of inhalers , have a written personal asthma action plan (PAAP) , have a written discharge/weaning salbutamol information leaflet , know how to recognise signs of deterioration and the actions to take , complete asthma discharge bundle

Rx. The following are 4 keys for asthma management:- حاله من حال اي chronic conditions .. العلاج يبدي من تثقيف الاهل ، الابتعاد عن المحسسات ، مراجعات دورية ، والادوية 1. Asthma checkups; follow-up of asthma should be every 2-4 wk until good control is achieved, then 2-4/yr to maintain good control. 2. Control of factors contributing to asthma severity 3. Asthma pharmacotherapy; 4. Patient education; Asthma pharmacotherapy : Long-Term Controller Medications:- Inhaled Corticosteroids (ICS) e.g. Beclomethasone, Triamcinolone, Flunisolide, Fluticasone, Mometasone, & Budesonide. Long-acting Inhaled β-agonist (LABA) Theophylline NSAI agents : Cromolyn and Nedocromi Leukotriene-modifying agents : Montelukast Anti-IgE : (Omalizumab) Quick-Reliever (Rescue) Medications:- 1.Short-acting Inhaled β-agonists (SABA) e.g. Albuterol, Terbutaline, Pirbuterol, & Levalbuterol (which causes less tachycardia and tremor). They have a rapid onset of action that last for 4–6 hr. 2.Systemic Corticosteroids e.g. Prednisone, Prednisolone, or Methylprednisolone orally as short-course "burst" that mainly used for severe asthma exacerbations & sometimes for severe persistent asthma Long-term use of systemic corticosteroids (or high-dose ICS) needs monitoring of their SE as in the following:CBP (neutrophilia & lymphopenia), serum electrolytes (hypokalemia & hypocalcemia), blood sugar (hyperglycemia), BP (hypertension), weight (gain), height (↓ especially in the 1st years after therapy), bone age by Xray & DEXA (osteoporosis) & annual eye exam (cataract & glaucoma). Corticosteroids also can ↓ immunity & ↑ susceptibility to infectious diseases & mask the signs of inflammation. 3.Inhaled Anticholinergic agents e.g. Ipratropium bromide are mainly used in combination with SABA in acute severe asthma for children >12 yr; they have bronchodilator effect & ↓ mucus production. classification and mangement Principles of Asthma Pharmacotherapy: The major objective “persistent” asthma with anti-inflammatory controller medication. اول شي اسوي ، لازم احدد اذا الطفل يحتاج controllers كون العلاجات الانية Quick-Reliever (Rescue) غير كافية للسيطرة على الحالة بشكل عام ، وجود اي حالة من الحالات المدكورة ادناه ، يعني لازم اضيف علاج للسيطرة "علاجات تاثيرها طويل الامد" : -If an asthmatic child has asthma symptoms or uses quick-relief medication at least 3 times per wk, -Awakes at night due to asthma at least 3 times per mo Experiences asthma exacerbations at least 3 times per yr -Requires short courses of systemic corticosteroids at least 3 times a yr then that patient should receive daily controller therapy. classification Step 1: Mild Intermittent Asthma: ≤2️⃣ day/wk or ≤2️⃣ night/month Rx. Resque medications only without daily controller❌❌ بهاي الحالة ، ميحتاج علاجات مستمرة ، فقط عند الاختناق Rx. Step 2: Mild Persistent Asthma: >2️⃣ day/wk or >2️⃣ night/mo. Rx :Daily controller therapy by : low-dose ICS, or Montelukast Step 3: Moderate Persistent Asthma: daily symp or > 1️⃣ night/WEEK. Rx. Moderate dose ICS Low-dose ICS + Montelukast Low-dose ICS + LABA Step 4: Severe Persistent Asthma: continuous daily symp or frequent night symp. Rx. Moderate dose ICS + Montelukast High-dose ICS + LABA +/_ Systemic corticosteroids ملاحضات : بغض النظر عن الclass ، علاجات Quick-Reliever نستخدمها بال acute attack وبعد استقرار حالة الطفل يلا يتم وضع الخطة باستخدام ال controllers في حال السيطرة على الاعراض بشكل تام ، ننزل خظوه علاجية ، او نقلل الجرعة ، او تقليل تكرار العلاج Step down في حالة عدم السيطرة على الاعراض ، ناخذ خطوة نصعد خطوة step up ، بعدما نتاكد من الالتزام بالعلاج ، وصحة التكنيك

Part two 2️⃣ Symptoms and signs Breathlessness Wheeze 🔑 Cough 🔑 Nocturnal cough مثل ما اتفقنه على تغيير اثناء اليوم Tight chest Intermittent dry coughing +/_ expiratory wheezing are the most common chronic symptoms of asthma. Older children may report associated dyspnea and chest tightness; BY AUSCULTATION 🩺 : Expiratory wheezing and prolonged expiratory phase +/_ diminished breath sounds in some ares of lungs More severe airway obstruction → inspiratory and expiratory wheezing or silent chest 🆘🆘 Symptoms and signs tend to be: variable 🔑 intermittent worse at night 🔑 provoked by triggers, including exercise 🔑 1️⃣. CXR🩻🩻 may be normal or may show hyperinflation. Generally not performed unless there is suspicion of complications or to exclude other diagnosis . الغرض هو استبعاد وجود مشكلة اخرى او جود مضاعفات اكثر من تشخيص الربو 📍📍 2️⃣ Pulmonary Function , shows obstructive pattern of lung disease من خلال قراءات واختبارات محددة ، تاكد وجود ال obstructive pattern كما موضع اسفل ⬇️ ⭕️ Spirometry; it can measure FEV1SEC , FVC, & FEV1 /FVC compared with the predicted norms based on gender, height, & ethnicity. It is only suitable for children >6 Y O FEV1 : حجم الهواء اللي يكدر المريض يطلعه بقوة خلال أول ثانية وحدة من الزفير أثناء فحص السبايرومتري FVC : هو إجمالي كمية الهواء اللي يقدر المريض يطلعها بعد شهيق عميق وبأقوى زفير ممكن أثناء فحص الـ Spirometry بهذا التحليل ، ناخذ قيمة FVC المتوقعة لنفس العمر ، الجنس ، الطول، والبيئة المحيطة الي تعيش بنفس الظروف ونشوف نسبة ال FEV1 للطفل لهاي النسبة 60-80 % moderate airway obstruction Less than 60 % indicates severe obstruction. ⭕️Bronchodilator response to an inhaled β-agonist is greater in asthmatics versus non-asthmatics with an improvement in FEV 1 ≥12%. (REVERSIBILITY)💡💡 زيادة الFEV1 بعد استنشاق موسع للقصبات بنسبة 12% يعتبر مؤشر للتشخيص ⭕️ Exercise challenges can identify children with exercise-induced bronchospasm → worsening of FEV 1 >15%. نقصان ال FEV1 بنسبة تزيد عن ال 15 بعد التمرين يعتبر مؤشر للتشخيص ⭕️ Peak Expiratory Flow (PEF) monitoring devices provide a simple and inexpensive home use tool to measure airflow resistence; it can measure PEF variation during the day after comparison with the best (not the predicted) value, if >20% indicate significant obstruction توضيح للاجراء 1. المريض يقيس PEF اكثر من مرة في اليوم (عادة صباحًا ومساءً) بعد شهيق عميق وزفير بأقصى قوة. 2. يسجل احسن قيمة شخصية اله (personal best) خلال فترة المتابعة. 3. نحسب التغير اليومي: إذا الفرق بين أعلى وأدنى قيمة >20% فهذا يدل على انسداد متغير مهم في الشعب الهوائية (diurnal variation)🔑

ASTHMA : 🆘🆘 PART 1️⃣ WHEEZE 🔑, DRY COUGH 🔑, SOB 🔑 VARIABILITY 🔑 DIURNAL VARIATIONS 🔑 FAMILY HISTORY 🔑 OTHER ALLERGIC CONDITIONS 🔑 chronic inflammatory condition of the lung airways resulting in episodic airflow obstruction due to airways hyperresponsiveness to a provocative exosures (triggers). يكون استعداد عند المصاب لاسباب وراثية وبيئية للتفاعل مع المحسسات ( غبار، عطور ، تدخين ، جو بارد ،تمارين او التهاب للمجاري التنفسية العليا… الخ) بشكل اكثر من الطبيعي مما يؤدي الى تضيق وزيادة مقاومة للهواء بشكل متكرر REOCCURRENCE ، ونفس الوكت REVERSIBLE مع وجود DIURNAL VARIATIONS اختلاف شدة الحالة خلال اليوم . ممكن ملاحظة اعراض تحسسيه اخرى مثل حساسية الجيوب الانفية ، حساسية جلدية .. الخ Co-morbid conditions include: Rhinitis, Sinusitis & Gastroesophageal reflux. These are also indirect triggers to asthma. There are 2 types of childhood asthma:- 1️⃣. Recurrent Wheezing of early childhood that primarily triggered by common viral RTI; it usually disappear by 6 yr of age (see Bronciolitis). عبارة عن تهيج وتحسس للمجاري التنفسية غالبا يكون بعد التهاب المجاري الننفسي العليا (بلهجة الاهل النشلة نزلت على صدره) ، يروح بالعادة عند ال ست سنوات وما اسمي ربو بهاي المرحلة .. الا اذا استمر بعد الست سنوات 2️⃣ . Chronic (Persistent) Asthma that persist into later childhood and often adulthood. It usually associated with the following risk factors : Parental asthma. احد الوالدين مصاب بالربو Allergy e.g. atopic dermatitis, allergic rhinitis, food allergy, or inhalant allergen sensitization. Severe lower RTI e.g. Pneumonia or Bronchiolitis. male gender hx of low birthweight wheezing apart from colds The above risk factors can be divided into major & minor criteria that help in the prediction of asthma: Major Criteria include: Parent asthma, Atopic eczema, & Inhalant allergen sensitization. Minor Criteria include: Allergic rhinitis, Wheezing apart from colds, Food allergen sensitization, & Eosinophils ≥ 4%. 1 major or 2 minor criteria provide prediction for persistent asthma into later childhood مو بالشرط ان تكون دقيقة ، تساعد ع التوقع فقط To be continued

GOLDEN KEYS WHEEZE 🔑 START WITH CORYZAL SYMPTOMS 🔑 FEVER <38.5 🔑 YOUNGER THAN 2 Y 🔑 (6 months is the peak) والسؤال الوزاري مثال عن اهمية ال🔑للتشخيص

وزاري 📍 A 6-month-old girl is referred after her first episode of wheezing. She had rhinorrhea and cough for three days, followed by breathing difficulty. Her RR is 60 breaths/min., temperature is 38.2°C, Subcostal retraction and diffuse wheezing are observed Which of the following is the most likely diagnosis?