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LECTURE: BRONCHITIS. PNEUMONIA BRONCHIAL ASTHMA IN CHILDREN

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Title: LECTURE: BRONCHITIS. PNEUMONIA BRONCHIAL ASTHMA IN CHILDREN


1
LECTURE BRONCHITIS. PNEUMONIABRONCHIAL ASTHMA
IN CHILDREN
  • DEPARTMENT OF PAEDIATRICS
  • CHIEF PROF. Y.V.PROHOROV
  • LECTURER ASOC.PR.
  • E.A.TOLSTIKOVA

2
Bronchitis
  • is an inflammatory disease of bronchi of various
    etiology infectious (mostly viral), allergic,
    physical and chemical (so-called irritative
    bronchitis).
  • It may be acute or chronic. There are the
    following main forms of bronchitis acute simple
    bronchitis, acute obstructive bronchitis,
    bronchiolitis, recurring bronchitis, chronic
    bronchitis (primary and secondary).

3
Criteria of acute bronchitis
  • /. Clinical
  • - cough - dry and rough at the beginning of
    disease, gradually becoming productive
  • - symptoms of intoxication are not expressed
    greatly and quickly disappear
  • - symptoms of respiratory insufficiency are
    absent
  • - physical signs on percussion there is a
    slight tympanic resonance, on auscultation - dry
    and various bubbling rales, heard on both
    sides of lungs.

4
Obstructive bronchitis
  • is a variant of acute bronchitis which proceeds
    with respiratory tract obstruction because of
    bronchospasm, mucous edema, hypersecretion and
    pressure from without.
  • Signs of respiratory tract obstruction
    persistent, "spastic" cough, expiratory dyspnea,
    oral crepitations, dry and various bubbling rales.

5
Obstructive bronchitis
  • //. X-ray
  • - strengthened lung figure, at the same time
    absence of focal shadow
  • - signs of disturbances of bronchial
    permeability irregular pneumatisation of lungs
    (focus of hyper- and hypoventilation), lobular
    atelectasis.
  • ///. Laboratory
  • - hematological normal leukocyte count or
    leukopoenia, lymphocytosis, monocytosis.
  • Red blood cells are not changed. ESR is not
    increased.
  • Differentiatial diagnosis of acute bronchitis is
    associated with acute bronchiolitis, pneumonia
    obstructive bronchitis - with bronchial asthma
    paroxysm.

6
Acute bronchiolitis
  • is mainly a disease of the first months of life.
    It is attributed mostly to the respiratory
    syncytial virus, although many other viruses may
    lead to a similar disease. It is characterized by
    obstructive respiratory insufficiency and cyclic
    course.

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8
Criteria of bronchiolitis
  • /. Clinical
  • - respiratory insufficiency of obstructive type
    cyanosis of nasolabial triangle, expiratory
    dyspnea with retraction of flexible parts of
    breast.
  • spastic cough. At the peak of the disease cough
    is paroxysmal, in productive with scanty viscous
    sputum (for infants of the first months of the
    life asphyxial paroxysms are possible)
  • - physical findings high tympanic resonance on
    percussion, on auscultation - prolonged
    breathing out, on inspiration a lot of fine
    bubbling rales, crepitation on the both sides of
    lungs
  • - cyclic course the disease continues for 6-8
    days, and to 8-10,h day it may be completly
    recovered.

9
Criteria of bronchiolitis
  • //. X-ray
  • - distended lungs and diminished vascular
    picture. Then intensification of vascular picture
    as lungs distention is decreasing.
  • ///. Laboratory
  • - normal or decreased white blood cells count,
    lymphocytosis. ESR is normal or slightly
    increased.
  • Differential diagnosis is provided with pneumonia
    and acute bronchitis.

10
Recurrent bronchitis
  • Recurrent bronchitis is the disease with
    relapsing of acute bronchitis 2 and more times a
    year during 1-2 years. The absence of clinical
    obstruction and duration of clinical
    manifestation for 2 weeks and longer every
    relapse are common.
  • Phases of pathologic process exacerbation,
    remission.
  • Chronic bronchitis is a chronic spread
    inflammatory damage of bronchi with rebuilding of
    mucous secretory apparatus and sclerotic
    degeneration of deep layers of bronchial wall.
  • Phases of pathological process exacerbation,
    remission.

11
Criteria of chronic bronchitis
  • Clinical
  • - productive cough for several months during 2
    years
  • - permanent various rales
  • - 2-3 relapses in a year during 2 years
  • - the signs of lungs ventilation disturbances in
    remission phase.
  • Note none of the above mentioned signs may be
    regarded alone as reliable evidence of chronic
    bronchitis. The sings must be considered in
    complex in view of possible development of
    chronic process.
  • //. X-ray,
  • especially bronchography - increasing and
    deformity of lungs figure, the disturbances of
    the lungs hilus' structure.
  • ///. Bronchoscopy gives information about the
    character of endobronchitis. It is of great value
    for differential diagnosis.
  • Primary chronic bronchitis is diagnosed after
    exclusion of cystic fibrosis, bronchial asthma,
    lungs and cardiovascular malformations, ciliary
    dysgenesis.

12
Chronic bronchitis
  • Secondary chronic bronchitis - is complication
    of lungs and cardiovascular malformations, cystic
    fibrosis, hereditary diseases of lungs and a
    specific (tuberculosis) bronchial and pulmonary
    process.
  • Chronic obliterating bronchiolitis (COB) - is
    chronic inflammatory bronchial disease of viral
    or immunopathological origin which appears as a
    result of bronchi or bronchioles obliteration of
    one or several lungs lobes. It leads to lungs
    blood circulation disorders and development of
    emphysema.
  • Phases of pathologic process relapse, remission.
  • Forms of COB total one-sided, focal one-sided,
    focal two-sided, partial.

13
Criteria of chronic obliterating bronchiolitis
  • Clinical
  • - severe respiratory infection with obstructive
    syndrome in case history
  • - persistent fine bubbling rales under the
    weakened breathing.
  • //. X-ray
  • - one-sided weakening of lung figure, lessening
    of the lung field size on bronchogramme -
    unfilling by contrast of bronchi of 5-6th level
    and lower prominent decreasing of lung perfusion
    in zones of pathologic process.

14
Pneumonias
  • Pneumonia is an acute infectious inflammatory
    disease of various nature with involving of
    respiratory organs into pathologic process and
    intra-alveolar inflammatory exudation.
  • Classification of pneumonias
  • Groups of pneumonias
  • 1. Primary
  • 2. Secondary.
  • - In primary pneumonia pathologic process at
    first develops in lungs tissue and is considered
    as a basic disease.
  • - In secondary pneumonia pathologic process
    complicates the course of another pulmonary
    disease or diseases of other organs (the same
    concerns the chronic pneumonia).

15
Classification of pneumonias
  • Forms of pneumonias
  • - focal (focal confluent)
  • - segmental ( mono- or polysegmental)
  • - croupous
  • - interstitial
  • Localization of process lung, lobe, segment,
    one-sided, double (two sided).
  • Course of pneumonia
  • - acute
  • - - lingering (reverse development of pneumonia
    process not earlier than 6 weeks - 8 months after
    beginning of disease)
  • - recurrent (under exclusion of
    reinfection).

16
Classification of pneumonias (continuing)
  • Variety of pneumonias
  • Out-of-hospital ("home")
  • Hospital (nosocomial)
  • under perinatal infection - aspirative one
  • in patients with immune deficiency.
  • The type of infectious agent is connected with
    the variant of pneumonia in out-of-hospital
    pneumonias gram-positive cocci are predominant
    in hospital pneumonias - Staphylococci and
    Gram-negative microflora, in newborns -
    Chlamidias, Pneumocystas, Ureaplasmas, in
    aspirative pneumonia - obligate anaerobes
    combined with Gram-negative bacilli in case of
    prominent immune disorders - Pneumocystas, Fungi,
    Cytomegaloviruses.

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18
Complications
  • Pulmonary complications
  • - Synpneumonial pleurisy
  • - methapneumonial pleurisy
  • - pulmonary destruction
  • - pneumothorax, etc.
  • Extrapulmonary complications
  • - infectious - toxic shock
  • - DIG - syndrome
  • - cardiovascular insufficiency
  • - respiratory distress syndrome of adult type.

19
Criteria of pneumonia
  • 1. Anamnestic data
  • - connections with respiratory viral infections
    common cold.
  • 2. Clinical
  • - Syndrome of respiratory insufficiency
  • - dyspnea,
  • - participation of axillary muscles in
    breathing act, retraction of flexible parts of
    thorax, pallor of skin, cyanosis of nasolabial
    triangle or spread cyanosis, increasing after
    physical exertion
  • - Syndrome of intoxication
  • - worsening of feeling, sleep disturbances,
    decreasing of appetite, flaccidity, adynamia or
    hyperexcitability, motor anxiety, hyperthermia,
    muffled heart sounds, tachycardia.
  • For the infants of the first two months of
    life marked signs of intoxication are flaccidity,
    decreasing of appetite down to refusing of breast
    feeding, weight fall, decreasing of physiological
    reflexes, appearance of gastrointestinal
    disorders, development of exicosis
  • - Focal signs in lungs - they are prominent in
    segmental (polysegmental) and affluent
    pneumonias, less marked in focal pneumonias and
    minimal changes are supervised in interstitial
    pneumonias
  • a) on percussion - shortening of
    resonance on the place of lesion
  • b) on auscultation - harsh, bronchial
    or weakened bronchial breathing on the place of
    lesion
  • c) fine bubbling rales or crepitation
    rales above the infiltrative foci.

20
Criteria of pneumonia(continuing)
  • 3. X-ray infiltrative changes of lungs of focal
    or segmental type and reaction of lung's hylus
    on the side of lesion.
  • Such signs as emphysema, strengthening of hylus'
    figure (perivascular and peribronchial
    shadowings) may be supervised either in
    bronchitis and bronchiolitis or in pneumonia.
  • 4. Laboratory
  • Blood cell count shows the activity of bacterial
    inflammation increasing of ESR, leucocytosis,
    neutrophilia with shift to the left. In infants
    of the first months of life it is often seen
    lymphocyte reaction, early developed anemisation.
  • Differential diagnosis is provided with acute
    respiratory viral infections, bronchiolitis. In
    lingering course of pneumonia -with primary
    tuberculosis, cystic fibrosis.

21
         
         
22
Bronchiectasis
  • - congenital or acquired disease of progressing
    affection of bronchi, which is characterized as
    infectious inflammatory chronic process which
    leads to deformation of bronchi, namely their
    dilatation and disturbances of drainage function,
    blood and lymph circulation. Some authors regard
    bronchiectasis combined with pneumosclerosis as
    "Chronic pneumonia". Thus in various editions we
    meet the description of the same disease as a
    "Bronchiectasias" or "Chronic pneumonia".
  • Forms of disease slight, moderate or severe.
  • Periods of disease relapse, remission.
  • Localization - one-sided, two-sided, restricted
    (segment, lobe) and spread, with indication of
    localization and type of endobronchitis.
  • Types of bronchiectasis saccular (cyst-like),
    cylindrical, mixed.

23
Criteria of bronchiectasis
  • /.Anamnestic data
  • - frequent repeated pneumonias with the same
    localization of lesion with lingering course,
    which begin at early childhood and infancy
    severe pneumonias with lung destruction in the
    past.
  • I I. Clinical
  • - permanent productive cough, increasing during
    exacerbation, with production of mucopurulent
    sputum, more often in morning
  • - syndrome of chronic intoxication pallor, grey
    skin, quick fatiguability, bad appetite,
    worsening of feeling
  • - syndrome of chronic heart-pulmonary failure
    cyanosis of naso-labial triangle and
    acrocyanosis dyspnea and tachycardia after
    physical exertion, clubbed fingers, curvature of
    the nails in their long axis (like "watch
    glasses")
  • - thorax deformation asymmetry of the thorax
    retraction or protrusion of separate parts. May
    be lag of one part of the thorax in the time of
    breathing
  • - physical finding are characterized as stable
  • a) on percussion - shortening of resonance or
    tympanic tint above the lesion zone
  • b) on auscultation - changing of breathing
    depending on the expression of process (harsh,
    bronchial sometimes amphoral, may be weakened ).
    Stable various moist and dry rales.

24
Criteria of bronchiectasis
  • ///. Instrumental
  • - ?-ray on X-ray film made in remission there is
    a strengthened lung figure, thickening of
    bronchi walls of one or several segments,
    diminishing of separate lung segments
    (pneumosclerosis).
  • - Bronchoscopy bronchial deformation, saccular
    or cylindrical bronchiectasis, endobronchitis of
    different type (catarrhal, purulent etc.).
  • - Bronchography bronchiectasis of various forms
    (cylindrical, saccular).
  • - Spirography decreasing of reserve ability
    of external breathing, stable respiratory
    insufficiency.
  • - Pneumotachometry disturbances of bronchial
    condition permeability.
  • IV. Laboratory findings
  • 1) WBC - inflammatory changes are present in
    relapse and absent on remission.
  • 2) Immunological findings
  • decreasing of secretory immunoglobulin A and G in
    bronchial content
  • - decreasing of serum immunoglobulin A and G.
    Differential diagnosis is provided with recurrent
    bronchitis
  • repeated, lingering pneumonias, tuberculosis of
    the lungs.

25
Bronchial Asthma (BA)
  • According to the modern concept BA is chronic
    inflammation of respiratory tract with spread but
    varying obstruction with hypersensitivity to
    different agents caused specific immune
    (sensibilisation, allergy) or nonimmune
    mechanism. Prominent clinical sign of disease is
    an attack of difficult breathing (dyspnea)
    because of bronchial obstruction, hypersecretion
    of mucous, edema of bronchial walls.
  • Types of obstruction
  • Acute - spasm of smooth muscles of bronchi.
  • Subacute - edema of mucous of respiratory tract.
  • Chronic - hypersecretion of tenacious mucus,
    which obturates terminal parts of respiratory
    tract.
  • Sclerotic changes in bronchial wall.
  • Forms of disease
  • Atopic (exogenous).
  • Nonatopic (endogenous).
  • Mixed.

26
Criteria of Bronchial Asthma
  • 1. Atopic anamnesis.
  • 2. Paroxysms of dyspnea.
  • 3. Spasmatic cough (especially at night and on
    physical exertion and difficult expiration),
    accompanied with acute inflammation of lungs.
  • 4. Asthmatic status.
  • 5. Periodic manifestations of symptoms,
    wheezing in the children of early age more than 3
    times.
  • 6. X-ray at attack there are signs of
    enrichment of bronchiovascular picture.

27
  • A child may have one or more signs, which are
    used for estimation of the severity of the
    disease. The patient has to be referred to the
    most severe group if he reveals even only one
    sign proper to this group. If the patient with
    severe course of BA corresponds to more easy
    forms of disease, but receives drugs treatment
    corresponding to severe form it is necessary to
    diagnose the severe BA.
  • Complications
  • - Atelectasis,
  • - spontaneous pneumothorax,
  • - subcutaneous and mediastinal emphysema,
  • - pulmonary emphysema,
  • - pulmonary heart etc.

28
Criteria of Severity of BA in children
  • SignsMildModerateSevere
  • Frequency of attacksNot more than 1 a month3-4
    times a monthSeveral times a week or every day
  • Clinical characteristic of attacksEpisodical,
    quickly disappearing, easyAttacks are accompanied
    with external expiration disturbances
  • Permanent presence of symptoms, severe attacks,
    asthmatic statusNight attacksAbsent or easy2-3
    times a weekAlmost every 24 h
  • Tolerance to physical exertion, activity, sleep
    disturbancesNot changedDecreasedEssentially
    decreasedIndex of FEVI and PEF80 and more (as
    compared with normal)60Less than 6024 hours
    changes in bronchial permeabilityNot more than
    2020-30Over 30Characteristic of remission
    period3 and more monthsLess than 3 months1-2
    monthsPhysical developmentNot disturbedNot
    disturbedPossible retardation and disproportion
    of physical developmentThe methods of arrest of
    the attacksThe attacks disappearSpontaneously or
    by means of single reception of broncholitics (in
    the form of inhalation, orally)
  • The attacks arearrested by broncholitics (inthe
    form of inhalation and parenterally),
    corticosteroid drugs are administrated
    parenterally if indicatedThe attacks are arrested
    at the hospital with the of broncho- and
    spasmolitics. Simultaneously with
    corticosteroidsBasic anti-inflammatorytreatmentInh
    alative corticosteroids in the moderate
    dosesInhalativecorticosteroids in the moderate
    dosesInhalative and systemic corticosteroids

29
Criteria of Severity of BA attacks
  • SignsMildModerateSevereStatus asthmaticus
  • Physical activityPreservedLimitedForced
    positionAbsentSpeechPreservedLimited. Not fluent
    speech, speech consists of separate phrasesNot
    fluent speechAbsentConsciousnessSometimes
    excitationExcitationExcitation, fear,"breathing
    panic"Confused unconsciousness hypoxe-michypercapn
    emic comaRespiration rateRespiration is
    acceleratedExpressed expiratory dyspneaVery
    expressed expiratory dyspneaBradypnea,
    tachypneaParticipation of axillary
    musclesExpressed a littleExpressedExpressed very
    muchParadoxal toraco-abdominal respirationWheezing
    Usually at the end of expirationExpressedExpressed
    very much"Dumb" lungs, absence of respiratory
    soundsPulse rateAcceleratedAcceleratedAccelerated
    very muchBradycardiaFEVI, PEF in of norms of
    best patients valueMore than 8060-80Less than
    60Pa02NormalMore than 60 mm HgLess than 60 mm
    HgPaC02NormalLess than 45 mm HgMore than 45 mm Hg

30
Treatment of BA
  • BASIC
  • Ingalation of Glucocorticoides
  • Symptomatic
  • B-2 agonists holinolitics

31
LECTURE Nephropathies in children
  • DONETSK NATIONAL MEDICAL UNIVERSITY
  • Department of Paediatrics
  • Chief Prof. Y.V.Prohorov
  • LECTURER Asociated prof. E.A.Tolstikova

32
PYELONEPHRITIS (P)
  • P is an infectious inflammatory disese of
    tubulointerstitial renal tissue.
  • Diagnostic Criteria
  • I. CLINICAL
  • Intoxication Syndrome
  • Weakness, indisposition, bad appetite, loss of
    weight.
  • In babies vomiting, meningeal symptoms,
    toxicosis, exicosis.
  • Painful Syndrome
  • Pains in abdomen and lumbur region in the
    absence of any complaints it is necessary to
    reveal them actively (palpation of abdomen, jerk
    on lumbar region Pasternatskiy symptom)
  • Disuria
  • frequent and painful micturitions.

33
Renal Syndrome
  • leukocyturia - from moderate to significant up to
    pyuria leukocyturia with more than 5-7
    leukocytes in vision field is demonstrative,
    neutrophils are prevalent. In the absence of
    demonstrative leukocyturia it is necessary to
    carry out the tests of Amburgeau, Addis-Kakowsky,
    Nechiporenko
  • bacteriuria - a colony count of over 100 000/ml
    can be taken as indicating significant
    bacteriuria. Evaluation of bacteri uria is made
    by taking into account of the type of a
    microorganism, its pathogenicity, the form and
    period of the disease, degree of activity of the
    process and patient's age.
  • proteinuria - is not typical for pyelonephritis,
    usually it is mild (1 g/l)
  • hematuria is not typical for pyelonephritis, but
    it some times occurs in secondary
    pyelonephritis
  • restriction of tubular functions as to osmotic
    concentration (specific gravity is below 1020
    while diuresis is less than 1000ml/d). The renal
    signs of the disease are the most important ones
    in diagnosing of pyelonephritis, the extrarenal
    signs in some children may be absent, in others
    they may be latent.

34
II. DATA of EXCRETORY UROGRAPHY
  • a) in acute pyelonephritis
  • the kidney is enlarged by more than 1cm on the
    account of its parenchyma hypotonia of the
    ureters
  • b) in chronic pyelonephritis
  • - - asymmetry of the kidneys
  • - - decrease of renal parenchyma as compared to
    contralateral
  • - significant variations of its thickness in the
    same kidney in different places
  • - deformation of calyco-pelvic system
  • - irregular excretion of contrast substance up
    to adynamia of calico-pelvic system.
  • c) in chronic secondary pyelonephritis
  • - obstruction of the urinary tract
  • - congenital malformations
  • - refluxes
  • - renal dysplasia.

35
Clasification of pyelonephritis
  • FORM
  • 1. Primary.
  • 2. Secondary
  • - obstructive
  • - dysembriogenetic
  • - dysmetabolic
  • COURSE
  • 1. Acute
  • 2. Chronic
  • a) manifest recurrent form
  • b) latent form
  • PERIOD
  • Active
  • Partial remisson
  • Remission
  • RENAL FUNCTION
  • Without function s disorders
  • With function s disorders
  • Chronic renal insufficiency

36
Differential diagnosis
  • cystitis,
  • glomerulonephritis,
  • renal tuberculosis,
  • renal tumor,
  • urolithiasis.
  • Pyelonephritis lasting for 6 mo. and longer is
    regardedas chronic.

37
TREATMENT OF PYELONEPHRITIS
  • ANTIBIOTICS
  • Amoxicillin
  • cefalosporins
  • carbenicillin
  • NITROFURANS
  • 1. Furadonin
  • 2. Furagin 5 8 mg/kg divided in 4 intakes
  • 3. Nalidixic acid (negram, nevigramon)
  • 50-60 mg/kg in 4 intakes
  • 4. 5-NOK, nitroxolin 8-10 mg/kg in 4 intakes

38
Glomerulonephritis
  • Glomerulonephritis is an infectious allergic
    renal disease with primary lesions of glomeruli.
    Boys suffer twice more often than girls.
  • Diagnostic criteria
  • 1. Clinical
  • 1) Extrarenal symptoms
  • a) edemas - at first they occur on eyelids, face
    later they
  • may be generalized
  • b) arterial hypertension - more often
    hypertension is moderate, in some cases it may be
    absent.

39
2) Renal symptoms
  • a) oliguria and anuria are present in the
    initial period of acute glomerulonephritis, in
    this case urine has high specific gravity
    (1030-1040 and more)
  • b) hematuria of different degree - moderate
    (microhematuria) and massive (macrohematuria)
  • c) proteinuria
  • moderate - up to 1000 mg/l (daily loss is up to 1
    g)
  • significant - more than 1000 mg/l, up to
    2500-3000 mg/l (daily loss is 2,5-3 g)
  • - massive - more than 3000 mg/l (daily loss is
    more than 3 g).
  • leucocyturia - is nottypicalfor
    glomerulonephritis may be transitory
    leucocyturia of lymphoid character
  • cylindruria - hyaline, epithelial, granular, waxy
    casts.

40
3. Metabolic symptoms
  • disorders of water-electrolyte metabolism, which
    are characterized by different types of
    hyperhydration intracellular and extracellular
    in ionogram there is elevation or decreased
    level of some electrolytes in plasma and
    erythrocytes. These disorders are most
    significant in acute glomerulonephritis in
    oligoanuric period, in the development of acute
    and chronic renal insufficiency
  • disorders of protein metabolism are the most
    signifcant in high proteinuria and they are
    characterized by hypoproteinemia (total protein
    level is less than 60 g/l), hypoalbuminemia
    (albumins are less than 50), changes of
    globulin's fractions ratio
  • disorders of fat metabolism are present in some
    cases of glomerulonephritis and they are
    characterized by hypercholesterinemia
    (cholesterin is more than 5 mmol/l).
  • Mentioned above renal and extrarenal symptoms and
    metabolism disorders are seen in different cases
    of glomerulonephritis in various combinations.

41
Differential diagnosis
  • - glomerulonephritis
  • - pyelonephritis,
  • - renal tuberculosis,
  • - and tumor.

42
CLASSIFICATION OF GLOMERYLONEPHRITIS
  • A. FORM
  • 1. ACUTE GLOMERYLONEPHRITIS (AG)
  • a) with nephritic syndrome
  • b) with nephrotic syndrome
  • c) with isolated urinary syndrome
  • d) with nephrotic syndrome, hematuria and
    hypertention.
  • 2. CHRONIC GLOMERYLONEPHRITIS
  • a) nephrotic form
  • b) hematuric form
  • c) mixed form
  • 3. SUBACUTE (malignant) GLOMERYLONEPHRITIS.

43
B. ACTIVITY OF RENAL PROCESS
  • 1. ACUTE GLOMELURONEPHRITIS
  • a) Period of initial manifestations.
  • b) Period of comprehensive manifestations.
  • c) Period of reverse development.
  • d) Transition to chronic glomerulonephritis.
  • 2. CHRONIC GLOMERYLONEPHRITIS
  • a) period of exacerbation
  • b) period of part remission
  • c) period of full clinical and laboratory
    remission.

44
C. CONDITION OF RENAL FUNCTIONS
  • 1. ACUTE and CHRONIC GLOMELURONEPHRITIS
  • a) Without disorders of renal functions
  • b) With disorders of renal functions
  • c) Acute renal insufficiency
  • 2. SUBACUTE (malignant) GLOMERYLONEPHRITIS
  • a) With disorders of renal functions
  • b) Chronic renal insufficiency.
  • Glomerulonephritis lasting for 1 year and longer
    is regarded as to be chronic.

45
Interstitial nephritis
  • Interstitial nephritis (IN) is an abacterial
    inflammation of renal connective tissue with the
    following involvement of tubules, blood and
    lymphatic vessels of renal stroma in the
    pathologic process.
  • Diagnostic criteria
  • /. Clinical symptoms and signs of acute IN
  • vomiting
  • headache
  • pain in the lumber region
  • fever
  • skin eruptions
  • chill.

46
//. Laboratory symptoms
  • anemia
  • elevated ESR
  • acidosis
  • azotemia
  • hyperkalemia
  • hypostenuria, isostenuria
  • hematuria
  • leukocyturia of mononuclear or eosinophilic
    character
  • high activity of transaminidase in blood and
    urine
  • beta-2-microglobuiine in urine
  • antibodies to the protein of Tamm-Hoursefield.

47
Clinical signs and symptoms in IN
  • flabbiness
  • bad appetite
  • abdominal pains (renal colic)
  • osteodystrophy
  • lag of weight
  • Laboratory symptoms
  • hematuria
  • dysuria-polyuria
  • tubular acidosis
  • "salt-toss kidney".
  • Differential diagnosis is provided with
    pyelonephritis, diffuse and hereditary nephritis,
    renal tuberculosis, renal tumors, dysmetabolic
    nephropathies, urolithiasis.

48
Acute Renal failure (ARF)
  • Acute renal failure (ARF) denotes an acute
    impairment of renal function stipulated by sudden
    and sharp decrease of renal glomerular filtration
    rate and disorders of excretion of toxic
    substances, disturbances of water, electrolyte
    metabolism and acid-alkaline balance.
  • Diagnostic criteria
  • There are pre-renal, renal and post-renal
    (obstructive) ARF.
  • Important causes of ARF
  • A. Pre-renal
  • Acute gastroenteritis.
  • Hemorrhage.
  • Shock.

49
B. Renal
  • 1. Acute tubular necrosis
  • Fluid loss, hemorrhage, shock
  • Intravascular hemolysis
  • Sepsis
  • Nephrotoxic drugs, chemical, radiocontrast
    substances
  • Major surgical procedures, road accidents,
    extensive burns
  • Hepatic failure, congestive cardiac failure.
  • 2. Glomerular disease
  • Acute glomerulonephritis
  • Hemolitic uremic syndrome.
  • Interstitial nephritis.
  • Acute bacterial pyelonephritis.
  • Miscellaneous
  • Snakebite
  • Renal vein thrombosis.

50
C. Post-renal (obstructive)
  • Calculus,
  • blood dots,
  • crystals of uric acid,
  • sulphonamides.

51
Stages of ARF
  • Initial (preanuric).
  • Oligoanuric.
  • The stage of diuresis rehabilitation with the
    development of polyuria.
  • Convalescence.
  • The clinical picture of the initial stage depends
    on the diseases, which caused ARF.

52
  • Oligoanuric stage
  • - Pallor with icteric tint (sometimes
    hemorrhages, itching)
  • Adynamia, headache, flabbiness
  • Vomiting, nausea, diarrhea
  • Tachycardia, decrease of arterial pressure,
    disorders of rhythm and conduction
  • Noisy dyspnea
  • Convulsions
  • Abdominal pains
  • Lung's edema.
  • Polyuric stage
  • Polyuria (up to 10 I)
  • Anemia
  • Infectious complications

53
Chronic renal failure
  • Chronic renal failure (CRF) implies permanent,
    irreversible, severe decrease of renal function.
    As it is recommended by the 4th European congress
    of pediatricians-nephrologists it is necessary to
    diagnose CRF in the children with renal diseases
    when gtomerular filtration is less than 20
    ml/min/1,73m2, creatinine level is more than
    0,177 mmol/l and urea level is more than 5,8
    mmol/l.

54
1. Clinical
  • Tiredness, fatigue, headache, loss of appetite,
    vomiting
  • Polyuria, nicturia, polydypsia, bone and joint
    pains, retardation of growth, dryness and itching
    of skin
  • Muscular convulsions, paresthesias, signs of
    sensor or motor neuropathy
  • Heart failure and hemodynamic disorders.
  • //. Laboratory
  • Decrease of glomerular filtration rate
  • Metabolic acidosis
  • Anemia
  • Decrease of thrombocytes' adhesion
  • Hyperkalemia, hyperphosphatemia, hypocalcemia,
    hypoproteinemia, hyperuricemia
  • Isostenuria
  • Renal osteodystrophy
  • X-ray examination of the chest may reveal
    cardiomegaly, hypertrophy of the left ventricle,
    aortectasia, lung's edema, pleural exudate.

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Cause of CRF
  • /. Glomerular diseases
  • a) Glomerulonephritis
  • - of unknown etiology
  • associated with systemic lupus erythematosus
    (SLE), polyarteriitis nodosa
  • Henoch-Schbnlein vasculitis.
  • b) Familial nephropathy
  • nephronophthisis
  • Alport's syndrome.
  • Hemolytic uremic syndrome
  • Amyloidosis.

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  • 2. Congenital anomalies
  • bilateral renal dysplasia
  • Reflux nephropathy.
  • Obstructive nephropathy
  • pelviureteric junction obstruction
  • posterior urethral valve
  • calculi.
  • 3. Miscellaneous
  • - bilateral Wilms1 tumor.

57
Dysmetabolic nephropathies
  • Dysmetabolic nephropathies (DN) are renal lesions
    because of the severe disorders of metabolism.
    All the children with dysmetabolic nephropathies
    have pathology of the bile ducts. Hyperoxaluria
    may be primary (rare hereditary enzymopathy with
    elevated synthesis of oxalates) and secondary
    (hereditable on polygenic type family instability
    of membranes).

58
Diagnostic criteria of DN
  • /. Clinical
  • recurrent pains in joints and their swelling
  • abdominal pains (renal colic)
  • lesions of the lungs.
  • //. Laboratory
  • hematuria
  • elevated urine level of glycolate, glyoxalates
    and oxalatesin the primary type and D-glyceric
    acid with oxalates in thesecondary type
  • elevated daily excretion of oxalates.

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//. Laboratory findings
  • - elevated blood and urine level
  • (more than 3,9 mmol/l and 3,6 mmol/day
    correspondingly) of uric acid.

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LECTURE
  • CARDIOLOGYCongenital Heart Diseases
  • DONETSK NATIONAL MEDICAL UNIVERSITY
  • Department of Paediatrics
  • Chief Prof. Y.V.Prohorov
  • LECTURER Asociated prof. E.A.Tolstikova

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Patent ductus arteriosus (PDA)
  • Patent ductus arteriosus is a communication
    between the pulmonary artery and the aorta. The
    incidence is about 20 among all congenital heart
    diseases it occurs more often in girls.
  • Hemodynamics
  • PDA results in left-to-right shunt from the aorta
    to the pulmonary artery. The increased flow after
    passing through the lungs reaches the left atrium
    which enlarges in size. The left ventricle
    receives the increased volume of blood that
    causes its dilatation.

62
Diagnostic criteria
  • /. Anamnestic.
  • Recurrent pneumonias, respiratory infections.
  • //. Clinical.
  • Continuous systolic and diastolic murmur is
    audible with maximum in the second left
    interspace as well as the accentuated 2nd tone
    over the pulmonary artery and below the left
    clavicle.

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///. Instrumental.
  • - ECG reveals the signs of overloading of the
    left ventricle or of both ventricles.
  • - PCG reveals highly amplitude systolic and
    diastolic murmur in the second left interspace,
    increase of the amplitude of the second sound.
  • - EchoCG reveals increase of cavities of the
    left atrium and the left ventricle, increase of
    motion amplitude of the mitral valve the
    diagnosis of PDA may be confirmed by Doppler.
  • - Radiography reveals the lung fields appearing
    plethoric (hypervolemia), increase of the left
    ventricle and the left atrium, aortic arch is
    marked.

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Atrial septal defect (ASD)
  • Atrial septal defect is an abnormal communication
    between the two atria. The ostium primum type of
    the defect is located inferior to the fossa
    ovalis, the ostium secundum type is generally
    anatomically located at the fossa ovalis. Atrial
    septal defect constitutes 8-16 of all congenital
    heart diseases, it occurs twice more often in
    girls.

65
Hemodynamics
  • The right atrium receives blood not only through
    the superior and inferior vena cava but also the
    blood, shunted from the left atrium. The right
    atrium gets larger in size to accommodate the
    extra volume of blood, so does the right
    ventricle. The cardiac apex is formed by the
    enlarged right ventricle. The pulmonary artery
    and its branches are enlarged as well.

66
Diagnostic criteria
  • /. Clinical
  • . Moderate systolic murmur is audible with
    maximum in the 2nd-3rd left interspace near the
    sternum the second sound over the pulmonary
    artery is widely split and accentuated.

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//. Instrumental.
  • - ECG - this is characterized by right axis
    deviation and right ventricle hypertrophy, right
    bundle-branch block
  • - PCG reveals moderate and low amplitude
    systolic murmur in the 2nd-3rd left interspace,
    increase of amplitude of 2nd sound over the
    pulmonary artery
  • - EchoCG reveals increase of the right ventricle
    cavity, paradoxical ventricular septal motion.
  • - Radiography reveals from mild to moderate
    cardiomegaly, right atrial and right ventricular
    enlargement, prominent main pulmonary artery
    segment, a relatively small aortic shadow and
    plethoric lung fields.

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Ventricular septal defect (VSD)
  • This is a communication between the two
    ventricles. Anatomically 90 of all ventricular
    septal defects are located in the membranous part
    of the ventricular septum with a variable
    extension into the adjacent muscular part of the
    septum, others are located in the muscular septum
    and can be multiple.
  • VSD is the most common congenital cardiac lesion
    and accounts for 15-25 of all congenital heart
    diseases, it occurs equally often in boys and
    girls.

69
Hemodynamics
  • Large septal defect (more than 1.5cm) leads to
    great shunt of blood from the left ventricle to
    the right one, overloading of vessels of lesser
    circulation, the left atrium and the left
    ventricle.

70
Diagnostic criteria
  • /. Anamnestic
  • Recurrent pneumonias, respiratory infections.
  • //. Clinical
  • a) arrested physical development
  • b) cardiac humpback
  • c) systolic thrill in 3rd-5,h left interspace
    at the sternal border
  • d) enlargement of borders of relative heart
    dullness
  • e) rough systolic murmur over all cardiac
    regions, accentuated 2nd sound over pulmonary
    artery.

71
III.Instrumental
  • - ECG reveals the signs of overloading of left
    cardiac parts later, as pulmonary hypertension
    develops, the signs of right ventricle
    hypertrophy appear
  • - PCG reveals highly amplitude systolic murmur,
    increase of amplitude of the 2nd sound over the
    pulmonary artery
  • - EchoCG reveals increased left atrial and
    ventricle size as well as exaggerated mitral
    valve motion.
  • - Radiography reveals the cardiac silhouette of
    the left ventricle type with the heart size
    depending on the size of the left-to-right shunt,
    increased pulmonary vasculature.

72
Coarctation of the aorta
  • Congenital coarctation of the aorta is located at
    the junction of the arch with the descending
    aorta. It constitutes 15 of all congenital heart
    diseases and occurs more often in boys.
  • Hemodynamics
  • Arterial pressure above the narrowing is
    elevated, the left ventricle experiences the
    overload with pressure. Arterial pressure distal
    to narrowing is decreased blood supply is
    accomplished on account of collateral vessels.

73
Diagnostic criteria
  • /. Clinical
  • a) complaints of a headache, nasal hemorrhages,
    fall of temperature of lower extremities
  • b) physical examination shows a good development
    of shoulder girdle, underdevelopment of lower
    extremities
  • c) arterial brachial pressure is elevated,
    femoral pressure is decreased or is not
    determined at all
  • d) moderate systolic murmur over all cardiac
    region is heard, with the point of maximum
    intensity over the back in the interscapular area.

74
//. Instrumental
  • - ECG reveals signs of the hypertrophy of the
    left ventricle
  • - EchoCG reveals myocardial hypertrophy of the
    left ventricle using suprasternal approach
    coarctation can be visualized and the gradient
    across the narrowing is obtained with Doppler.
  • - Radiography reveals increase of the left
    ventricle, enlargement of the ascending aorta
    aorta's arch is frequently not differentiated.

75
Tetralogy of Fallot (TF)
  • This is the most common cyanotic congenital heart
    disease in children above the age of two years
    constituting almost 75 of all blue patients.
    The overall incidence of TF is 12-14.
  • Anatomically TF consists of a ventricular septal
    defect associated with the obstruction of the
    right ventricular outflow in the form of
    infundibular or infundibular plus valvular
    pulmonic stenosis.
  • The four constituents of tetralogy as describea
    ?riginally by Fallot are a) ventricular septal
    defect, b) pulmonic stenosis, c) overriding or
    dextraposed aorta, and d) right ventricular
    hypertrophy.

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Hemodynamics
  • Physiologically the pulmonic stenosis causes
    concentric right ventricular hypertrophy without
    cardiac enlargement and an increase of the right
    ventricular pressure. When the right ventricular
    pressure is as high as the left ventricular or
    the aortic pressure, the right-to-left shunt
    appears to decompress the right ventricle. As
    soon as the right and the left ventricular
    pressures become identical, increasing severity
    of pulmonic stenosis reduces the flow of blood
    into the pulmonary artery and increases the
    right-to-left shunt. As the systolic pressures
    between the two ventricles are identical there is
    little or no left-to-right shunt, and the
    ventricular septal defect is silent. The
    right-to-left shunt is also silent since it
    occurs at insignificant difference in pressure
    between the right ventricle and the aorta. The
    ventricular septal defect of TF is always large
    enough to allow free exit to the right-to-left
    shunt. Since the right ventricle is effectively
    decompressed by the ventricular septal defect,
    congestive failure never occurs in TF.

77
Diagnostic criteria
  • /. Clinical
  • a) cyanosis of the skin and the mucous membranes
    (from light blue to intensive violet colour),
    which may be present from birth or makes its
    appearance some months or years after birth
  • b)anoxic spells (paroxismal attacks of dispnea)
  • c) sitting posture - squatting
  • d) physical examination discloses rough
    systolic murmur in the 2nd-3rd left interspace,
    the flapping 1st sound at the apex, the weakened
    2nd sound over the pulmonary artery

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//. Instrumental
  • - ECG reveals right axis deviation with right
    ventricular hypertrophy, "P" - pulmonale may be
    present
  • - PCG reveals rhombic systolic murmur in the
    2nd-3rd left interspace
  • - EchoCG reveals the large overriding aorta, the
    right ventricular hypertrophy and outflow
    obstruction
  • - Radiography reveals the normal-sized heart
    with the upturned apex suggestive of the right
    ventricular hypertrophy, the absence of the main
    pulmonary artery segment gives it the shape
    described as "Cor-en-Sabot" the pulmonary fields
    are oligemic.

79
Classification of congenital heart diseases (by
Marder)
  • Disorders of hemodynamics
  • With enriched pulmonary blood flow
  • With diminished pulmonary blood flow
  • With diminished greater circulation
  • Without disorders of hemodynamics
  • Disorders of hemodynamics
  • Without cyanosis
  • With cyanosis
  • With enriched pulmonary blood flow
  • Patent ductus arteriosus,
  • atrial and ventricular septal defects,
  • atrioventricular communication
  • Eisenmenger's complex,
  • transposition of great vessels,
  • common arterial trunk

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  • - With diminished pulmonary blood flow
  • Stenosis of the pulmonary artery
  • Fallot's disease, tricuspid atresia,
    transposition of great vessels with stenosis of
    the pulmonary artery,
  • Ebstein's anomaly, common false arterial trunk
  • - With diminished greater circulation
  • Aortal stenosis,
  • coarctation of the aorta

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Without cyanosis
  • Patent ductus arteriosus,
  • atrial and ventricular septal defects,
    atrioventricular communication
  • Stenosis of the pulmonary artery
  • Aortal stenosis,
  • Coarctation of the aorta
  • True and false dextrocardia,
  • Anomalies of the aorta position and its branches,
  • Small defect of the muscular part of the
    ventricular septum

82
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