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lecture 5

RESPIRATORY SYSTEM
1. The nose, like the whole front part of the skull of early age the child is
small. Moves narrow lower nasal passage is absent, it becomes clear to 4 years of
age, mucosa delicate structure of the nose.
2. The sinuses are formed to 2 years and is fully developed in the prepubertal
period.
3. Throat - at an early age is relatively short and narrow. Pharyngeal
lymphatic ring in the newborn developed inadequate
but; tonsils at an early age are deep between the arches, to 4-10 years in the
lymphatic tissue grows, starting with 13-14 almonds start to regress.
4. Larynx - relatively short and wide, funnel-shaped, with a thin pliable
cartilage and muscles. The angle of inclination of the epiglottis in children less than
adults. Especially intensively growing at 1 year of age. Sex differences in its
structure appear to 3 years. In the wall of the throat a large number of lymphatic
tissue.
5. The trachea - at an early age has a elliptical shape, the soft cartilage, the
mucosa is rich in blood vessels and mucous glands. tracheal length increases with
the growth of the body.
6. The bronchi - right bronchus is wider and shorter, continues trachea. Left -
a long and narrow. The angle of discharge of the same. Neonates
glubokovetvyaschayasya bronchi system, ie large bronchial branches reach the lung
cortical layer. branching type is gradually changing, and ends finally to 7 years.
Distinguish right and left main bronchus, equity, subdolevye, lobular, subdolkovye,
segmental, subsegmentary and terminal bronchi.
7. Light grow continuously by increasing the alveolar volume. lung mass
biggest increases in the first 3 months of life, and in 13-16 years. The histological
structure of lung tissue in infants is characterized by the number of loose
connective tissue in the interlobular septa and poverty elastic fibers. The basic
structural unit of the lung - acinus consisting of respiratory bronchioles I, II, III
order. In young children, they have wide gaps, but low in the alveoli. The roots of
the lung on chest radiograph also look like an adult to 10 years.
Children pneumonic process is most often localized in certain segments, due
to the characteristics of the data segments aeration, drainage function of bronchi,
the evacuation of them secret and the possibility of getting infections. The most
common pneumonia is localized in the lower lobe, namely in the apical-basal
segment (Figure 5). This segment is isolated to some extent from the other
segments of the lower lobe; its segmental bronchus departs above the other
segmental bronchus and is at a right angle straight back. This creates conditions for
poor drainage, since an early age, children usually are long time in the supine
position. Along with the defeat of the 6th segment of pneumonia often localized in
verhnezadnem segment of the upper lobe and the basal posterior segment of the
lower lobe. This explains the common form of the so-called paravertebral
pneumonia. A special place is occupied by the middle lobe lesion. With this type of
localization is acute pneumonia. There is even the term "srednedolevoy syndrome".
Fig.27.A chest radiograph.
Right-upper lobe pneumonia.

Figure 28. A chest radiograph.


Right hand pneumothorax (a
complication of pneumonia).

Fig.29. A chest radiograph.


Atelectasis of the right upper
lobe (a complication of
pneumonia).
Fig.30. Bronchograms right lung is normal.

Pleura- complete the structural differentiation to 7 years. Pleural cavity in


young children easily stretched due to poor fixing parietal layers.

Fig.30. A chest radiograph.


Interlobar pleurisy right

Especially respiratory physiology


Lung tissue in newborn straightened after 1-3 breaths. Premature this process
can take tens of seconds. In one inspiratory pressure difference in the gap and
pleural airways (transpulmonary pressure) is 10-15 times more than in the
subsequent quiet breathing. Stabilization alveoli state (nespadenie them) is carried
out through Surfactant - surface active agent which is formed pneumocytes and
consists of lipids. It covers the inner surface of alveoli, its lack of extensibility
when light is reduced and formed atelectasis. After the birth of the child breathes
40-60 times per minute. By 1 year, 35-50, 1-2 years - 30-35, 5-6 years - about 34-
25 times / minute, 10 years - 18-20, adults 16-15 times per minute. Vital capacity
(amount of air in ml after deep breaths) in infants 100-150ml. Level VC driven
body size and the degree of physical development. Functional maturation of the
respiratory system up to high school age. Respiratory diseases in children occur
much more frequently than in adults, are typically more severe, especially in
newborns, infants and young children.
Fig. 31. Hyaline membrane disease. Air bronchograms.

Investigation bodies Breathing usually starts with questioning the mother or


the baby, which is carried out in a certain sequence.
Cough - one of the most characteristic features of the defeat of the
respiratory system. The most typical cough in whooping cough; cough occurs
paroxysms (paroxysmal) with reprises (extended, deep breath), and is accompanied
by redness of the face and vomiting. paroxysms of coughing often occur at night.
Cough in the defeat of the larynx usually dry, rough and barking. It is so
characteristic that makes it possible at a distance of suspected laryngeal lesion
(laryngitis or croup). Cough with tracheitis rough (as in barrel). Bronchitis cough
may be either dry (early disease) and wet with sputum. In bronchial asthma is
usually separated viscous sputum. When inflammation of the lungs in the first days
of illness often cough is dry, the next day it becomes wet. With involvement of the
pleura process coughing becomes painful.
Bitonal cough - spasmodic cough having rough fundamental tone and higher
II musical tone arises from irritation cough zone of bifurcation of the trachea by
enlarged lymph nodes or mediastinal tumors and is observed in tuberculous
bronhoadenite (Fig.9), lymphogranulomatosis, lymphosarcoma, leukemia, tumors
of the mediastinum (thymoma , Kaposi et al.). Tormenting dry cough occurs with
pharyngitis and nasopharyngitis.

Figure 32. A chest radiograph.


Tuberculosis bronhoadenit.
Sometimes pneumonia marked abdominal pain (abdominal syndrome) that
makes suspect appendicitis and refer the child to a consultation with the surgeon.
When external examination should mark cyanosis, which may be permanent,
local or general. The more respiratory failure and less oxygen tension, the
expression and dissemination of cyanosis.

Figure 33.Signs of chronic oxygen insufficiency. The symptom of


"drumsticks" and "time windows".

When viewed from the oral cavity is necessary to pay attention to the state of
the pharynx and tonsils. In infants tonsils usually do not go beyond the front bow.
Children of preschool age there is hyperplasia of the lymphoid tissue and tonsils
out when viewed from the front of the bow.
A healthy child has a synchronous part in the breath of both halves of the rib
cage. When pleurisy can be seen that one of the halves of the thorax (ipsilateral)
behind during breathing.
On examination, it draws attention to the type of breathing. In young
children there is abdominal breathing. In boys, it remains unchanged, the girls from
5-6 years of age appears thoracic type of breathing. Restriction of chest rise
observed in acute swelling of the lungs, asthma, pulmonary fibrosis,
subdiaphragmatic abscess, intercostal neuralgia.
Figure 34. Chest radiograph in a patient with cystic fibrosis.

Figure 35. right lung hypoplasia.

Counting the number of breaths is best done in a minute, when the baby
sleeps.
In children with respiratory lesions observed a change in the ratio between
the frequency of breathing and pulse. In healthy children in the first year of life on
one breath has to 3-3.5 shock pulse in children older than one year on one breath -
4 stroke. In lesions lungs (pneumonia) and vary the ratio becomes 1: 2, 1: 3, since
the breathing rate increases more and pulse - to a lesser extent.
Fig.36. Bronchopulmonary dysplasia.

breathing slowing (bradypnea) in children is very rare and usually indicates a


depletion of the respiratory center.
On examination, the child should pay attention to participation in the breath
auxiliary muscles (rectus abdominis, sterno-clavicular, thoracic), which may
indicate breathing difficulty, that is, the shortness of breath. At the same time
young children as there is inflation and the voltage of the nose. Shortness of breath
occurs during hypoxemia, hypercapnia, an excess of various oxidized products
which accumulate in the blood and the brain matter, and acidosis.
There are the following forms of dyspnea.
inspiratory dyspnea. Observed with upper airway obstruction. Shortness of
breath during inhalation clinically retraction of the epigastric region, intercostal,
supraclavicular proctranstv, jugular fossa and the voltage of accessory muscles.
Expiratory dyspnea. The rib cage is lifted up, and almost does not
participate in the act of breathing. Rectus abdominis, on the contrary, are strained.
Exhale is slow, sometimes with a whistle. It is observed in bronchial asthma,
during partial compression of the bronchi.
Mixed dyspnea - inspiratory-expiratory. Manifested swelling and chest
indrawing of compliant places. Mixed shortness of breath characteristic of
bronchiolitis and pneumonia.
stenotic breathing It explains the difficult passage of air through the upper
airway (cereals, compression of the tumor), etc.
Asthma attacks - Asthma. Inhale and exhale at the same loud, lingering, often
heard at a distance. Characteristic of asthma.
Especially significant respiratory failure in infants observed in respiratory
distress syndrome, which is always accompanied by severe respiratory failure.
Respiratory distress syndrome is more common in premature babies.
Fig.37. Respiratory
distress syndrome.
Deep sternal retraction in
the act of breathing.

For respiratory distress syndrome, the child's cry at the birth of weak or even
absent. A marked hypotonia, decreased reflexes, pallor or cyanosis. Noteworthy is
that the breath of a child with a groaning breath, but without stenotic souffle,
shallow.
Palpation. Feeling the chest with both hands, which put her hands on his
chest studied areas symmetrically on both sides.
On palpation can reveal tenderness of the chest. It is necessary to distinguish
between superficial pain associated with superficial and deep tissues - pleural.
Pleural pain is usually aggravated by breathing in and out, often give in the
epigastric and hypochondrium, weaken if compress the chest (lungs decreases
mobility).
Voice tremor (fremitus vocalis) - the feeling that happens when put hands on
symmetrical portions of the chest of the patient cells on both sides, and the patient
at this time utters the words, which would provide greater vibration voice
(containing a large number of vowels and the sound of "p" For example, "thirty-
three", etc. in infants studied voice trembling while screaming or crying baby.
Strengthening the voice of jitter due to the sealing of the lung tissue (dense bodies
conduct sound better), in the presence of cavities in the lungs.
Voice jitter is attenuated by occlusion bronchus (lung atelectasis), and
pushing off from bronchial chest wall (exudate, pneumothorax, pleural tumor).
Percussion.Distinguish percussion indirect and direct. Indirect percussion -
percussion finger on the finger. When percussion great importance is the correct
patient position (symmetric position of both halves of the thorax). Percussion begin
with the comparative method to detect the change in the sound more clearly.
When percussion lung health is not always determined by the same lung
sounds. Right in the lower divisions of the proximity of the liver it is shorter than
the left because of the stomach close - tympanic shade (so-called space Traube
delimited from above the lower boundary of the heart and left lung, right - the liver
edge to the left - the spleen, from the bottom - costal arch, with fluid accumulation
in the pleural cavity it disappears).
Fig.38. Methods of indirect Fig.39. Methods of direct
percussion apex. percussion of the clavicle.

Fig.40. Method comparative Figure 41. Method comparative


percussion front. percussion axilla.
If it affects the respiratory variation appears different intensity of percussion
sound.
Shortening of percussion sounds notes:
1) with decreasing lightness lung tissue: a) Lung inflammation (edema and
infiltration of interalveolar septa and alveolar); b) with hemorrhages in the lung
tissue; c) with a substantial pulmonary edema (usually in the lower regions); g)
scarring of the lungs; d) at spadenie lung tissue - atelectasis, lung tissue
compression pleural fluid;
2) the formation of pulmonary cavities airless other fabric: a) in tumors, b)
the formation of cavities in the lungs and accumulates therein a liquid (sputum,
pus, cyst);
3) when filling the pleural space: a) exudates (pleural effusion) or transudate;
b) fibrinous deposits in the pleural sheets.
Tympanic sound shade It appears:
1) the formation of air cavities comprising: a) lung tissue destruction due
to inflammation (tuberculosis cavity lung abscess), tumors (decay), cysts; b) with
diaphragmatic hernia (Figure 12) and the air content cysts; c) in the pleura as
congestion in its cavity gas, air - pneumothorax (spontaneous pneumothorax
artificial);
Fig.42. Diaphragmatic
hernia on the left.

2) when a relaxation of pulmonary tissue due to the decrease of its elastic


properties (emphysema).
box sound - loud percussion sound to the tympanic shade appears when the
elasticity of the lung tissue is weakened, and the lightness of its increased
(emphysema).
Noise "cracked pot"- turns out to percussion of the chest while crying in
children with a number of diseases occurs in cavities communicating with the
bronchi narrow slit..
In determining the boundaries lung topographic percussion finger-plessimetr
is parallel to the desired boundary (ribs) in the interscapular area and - parallel to
the backbone.
The upper limit of the lungs in children is different depending on age.
Children of preschool age it is not defined as the top light does not go beyond the
collarbone.
In diseases of the lung borders are subject to change.
The lower lung boundaries are omitted due to an increase in lung volume
(emphysema, acute lung distension) or low stand aperture - the sudden deletion of
the abdominal organs and lowering intra-abdominal pressure, and paralysis of the
diaphragm.
Raised the lower boundary of the lungs when: 1) a decrease in the lungs as a
result of shrinkage of (often on one side in chronic inflammatory processes), 2) the
ousting of the lung pleural fluid or gas, 3) raising of the diaphragm due to an
increase in intra-abdominal pressure or depressor aperture up one way or another
organ or fluid (flatulence, ascites, enlargement of the liver or spleen, abdominal
swelling).
About mobility of the lower edges of the lungs in infants can be judged when
crying or screaming.
Auscultation. When listening first necessary to understand the nature of the
primary respiratory noise, and then to evaluate the adverse noise.
In infants and children aged 3-6 months tapped a few relaxed breathing, from
6 months to 5-7 years in children listened puerile respiration, which is essentially
an enhanced vesicular.
Children older than 7 years of breathing gradually takes on the character of
vesicular.
When listening to pay special attention to the following locations:
1. Axillary region - the early appearance of segmental bronchial respiration
during pneumonia;
2. Space on either side of the spine (paravertebral area) - frequent
localization of pneumonia in young children, especially over the spina scapula (the
defeat of the 2nd, 6th and 10th segments);
3. Between the spine and the scapula (area lung root) - early pneumonia and
infiltrative tuberculosis;
4. Subscapular region - early appearance crepitations;
5. Heart area - crepitus in the defeat of the tongue lobe of left lung.
Pathological changes in breathing
diminished breath observed:
1. with general weakening of the respiratory act;
2. at the closing of air in a certain part of the share;
3. with significant bronchospasm, syndrome obstruction caused by edema
and accumulation of mucus in the lumen of the bronchi;
4. when pushing off than any part of the lung;
5. with a strong thickening of the pleura.
increased breathing notes the narrowing of small or smallest bronchi.
hard breathing- a rough vesicular breathing with extended exhalation. It
usually refers to the defeat of bronchial tubes, meets with bronchitis and
bronchopneumonia.
bronchial breathing, Also known as tracheal or laryngeal may be reproduced
if the blow hole stethoscope or exhale breath with raised tongue tip and wherein the
pronounced sound of "x". Exhale heard ever stronger and longer than a breath.
In pathological states bronchial breathing auscultated only in cases of lung
tissue seal (segmental and lobar pneumonia, lung abscess).
crepitation are incremental and noises generated when moving or pneumatic
oscillation in cavities secretions, blood, mucus, edema fluid, etc. Rales are dry and
wet.
dry wheezing: Whistling - treble, bass and the high, low, more musical. Dry
wheezing call them because their formation fluid does not play a big role. They are
characterized by volatility and variability encountered in laryngitis, pharyngitis,
bronchitis, asthma.
bubbling raleformed by air passage through the liquid. Depending on the
caliber of the bronchus, where they are formed, they are finely, and
srednepuzyrchatymi krupnopuzyrchatymi.
It should be distinguished from wheezing crepitus, which is formed at
razlipanii terminal parts bronchioles. In these cases, the walls of the bronchial tubes
during exhalation stick together, and at the subsequent inhalation razlipayas cause
this sound phenomenon.
Pleural frictionFriction occurs when visceral and parietal pleura and listen
only under pathological conditions. This happens:
1. at pleura inflammation when it is covered with fibrin or on infiltration
foci are formed, which leads to irregularities, roughness pleural surface;
2. the formation as a result of inflammation of the delicate pleural
adhesions;
3. in lesions of tumor of the pleura, pleural tuberculosis;
4. at sharp dehydration (colibacillosis, cholera, etc.).
bronhofoniya - carrying voice and bronchi in the chest, determined by means
of auscultation. Reinforced bronhofoniya marked with the seal of the lung
(pneumonia, tuberculosis), atelectasis. Over caverns and cavities bronchiectasis, if
not blocked leading bronchus bronhofoniya also it is loud, with a metallic tint.
When sealing lung tissue reinforced bronhofoniya determined by the best
performing voice, while cavities - resonance.
X-ray methods of investigation
Chest radiography typically begins with X-rays to reduce radiation exposure.
In diseases of the transparency of the lung fields, light pattern (especially the
edges) change. Strengthening transparency of the lung fields with the most
significant emphysematous swelling (asthma).
When pneumothorax region occupied by a gas bubble is defined by the
bright field and enlightened pulmonary absence pulmonary pattern. On this
background it is preloaded light with a comparatively shade density and lack of
lung pattern.
A significant reduction in pulmonary transparency as a continuous uniform
dimming (in most cases one side) marked with lobar pneumonia share or individual
segments of the lung (segmental pneumonia) (Fig.14).
When focal pneumonia areas blackout blur, blurred, are small. When the
drain pneumonia large pockets.
The appearance of fluid in the pleural cavity depending on the amount of
lead to a certain decrease in the transparency of the lung.
Great diagnostic importance bronchography - a method based on the
introduction of contrast medium into the bronchi (e.g., lipiodol).
Tomography- method autotomography. When tomography images obtained
formations occurring at different depths of the chest due to special moving tube,
allowing to give a sharp image of only those structures that lie in a predetermined
plane.
Fluorography- the method of X-ray film with photographing on a special
attachment. This method is suitable for mass screening at clinical examination.
Fig.43.Chest radiograph in a patient against a background of asthma attack.
Determined by the increased airiness of lung fields

Fig.44. Right-focal-drain pneumonia middle lobe of the right lung.

Fig.45. Focal pneumonia-drain of the lower lobe of the left lung.


Fig.46. Right-sided pneumothorax

Figure 47.Miliary tuberculosis. Interlobar pleurisy on the right.

Fig. 48. Primary tuberculosis complex.

Methods of study of external respiration


spirography- method research of external respiration - made machine with a
closed air circulation and graphic recording of lung volume and pulmonary
ventilation. The study of external respiration is carried out in a calm state of
fasting.
The technique requires the active participation of the child and is used in
children 5 years and older.
Vital capacity (VC) - the maximum amount of gas that can exhale after the
maximum inspiration. Determined by the distance from the apex to the top of the
knee inspiratory expiratory knee and recalculated in milliliters. Boys vital capacity
greater than that of girls.
pneumotachometry - a method to judge the resistance to air flow, bronchial
conduction - one of the indicators of respiratory mechanics.
Oksigemografiya. oksigemografii principle is based on the measurement of
photoelectric absorption of light. Plot tissue is illuminated incandescent lamp. Light
passing through the tissue, hits the solar cell.
The sample with breath exhale(Stange probe). In this assay the greatest
interest is the time during which the blood oxygen saturation is not reduced.
Exercise testing. Exercise, consisting of 10-20 sit-ups in healthy children
does not lead to a decrease in blood oxygen saturation.
Test with inhalation of oxygen. In healthy children, when switching from air
to breathing oxygen breathing oxygen saturation is increased by 2-4% within 2-3
minutes. Increased saturation and slow increase points to uneven ventilation.
Laboratory Methods
Sputum. On microscopic examination, normally found under the microscope
white blood cells, red blood cells, squamous epithelial cells and mucus strands.
When lung disease can be detected a number of formations having diagnostic
significance. Elastic fibers are found in the sputum of lung tissue in the decay
(tuberculosis, abscess).
Investigation of pleural fluid. The fluid in the pleural cavity can be
inflammatory (exudate) and noninflammatory (transudate).
For typical exudate specific gravity greater than 1015, a protein content of 2-
3% and more positive reaction Rivalta (liquid turbidity when adding a weak acetic
acid solution). Cytology in the exudate are neutrophils in acute infections,
lymphocytes in tuberculosis.
Methodology pleurocentesis. Prick test is carried out in place of the greatest
stupidity, in some cases, also guided by fluoroscopy data and strictly aseptically.
respiratory distress syndrome
Respiratory failure is a condition of the body, wherein either not ensured the
maintenance of normal blood gas or recently achieved by abnormal operation of
external respiration apparatus, leading to a decrease in functionality of the
organism.
Fig.49. The appearance of a patient with respiratory failure and severe.

Distinguish 4 degrees of respiratory failure.


Respiratory failure level I characterized by the fact that at rest or not its
clinical symptoms, or they expressed slightly. However, with mild exertion appear
moderate dyspnea, cyanosis and perioral tachycardia. Normal blood oxygen
saturation, or may be reduced to 90% (pO2 8090 mm Hg) MOD increased and
MVL respiratory reserve and reduced with some increase in the basal metabolism
and the respiratory equivalents.
When the degree of respiratory insufficiency II alone observed moderate
dyspnea (the number of respirations increases by 25% compared with the norm),
tachycardia, pallor of the skin and perioral cyanosis. Changed ratio between the
pulse and breathing due to increased frequency of the latter, there is a tendency to
increase blood pressure and acidosis (pH 7.3), MVL (MOD), breathing limit is
reduced by more than 50%. Blood oxygen saturation was 70-90% (pO2 7080
mmHg). When oxygen giving the patient's condition improves.
When the degree of respiratory failure IIIbreathing dramatically speeded
(over 50%) is observed with cyanosis earthy shade, sticky sweat. Breathing
shallow, blood pressure is reduced, respiratory reserve drops to 0. The MOD
reduced. Blood oxygen saturation less than 70% (pO2 less70 mm Hg) observed
metabolic acidosis (pH less than 7.3) can be hypercapnia (pCO2 70- 80 mm Hg).
Respiratory failure degree IV- hypoxemic coma. Consciousness is lost;
arrhythmic breathing, intermittent, superficial. Observed general cyanosis
(akrozianoz), jugular venous distention, hypotension. Blood oxygen saturation -
50% or below (pO2 less50 mm Hg), pCO2 more 100 mmHg, and the pH is below
7.15. oxygen inhalation does not always bring relief, and sometimes causes and
deterioration of general condition.
Respiratory failure may also occur:
1. at pO2 decrease in inhaled air - anoksemicheskaya hypoxemia;
2. in lesions of respiratory failure may be due to lesion of the respiratory
muscles, disorders of the air passage of the airways (obstruction), disorders of
oxygen diffusion across the alveolar-capillary membrane;
3. in violation of the blood transport of gases. This occurs when severe
anemia (particularly post-hemorrhagic) or changing the structure of hemoglobin;
4. circulatory disorders - the so-called congestive hypoxia - greater oxygen
absorption occurs due to the deceleration of blood flow in organs and tissues;
5. a special place is occupied by the so-called tissue hypoxia, which is due
to the defeat of the enzyme systems of cells involved in the recycling of diffusible
oxygen from the blood.