Title: LECTURE: BRONCHITIS. PNEUMONIA BRONCHIAL ASTHMA IN CHILDREN
1LECTURE BRONCHITIS. PNEUMONIABRONCHIAL ASTHMA
IN CHILDREN
- DEPARTMENT OF PAEDIATRICS
- CHIEF PROF. Y.V.PROHOROV
- LECTURER ASOC.PR.
- E.A.TOLSTIKOVA
2Bronchitis
- 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).
3Criteria 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.
4Obstructive 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.
5Obstructive 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.
6Acute 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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8Criteria 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.
9Criteria 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.
10Recurrent 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.
11Criteria 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.
12Chronic 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.
13Criteria 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.
14Pneumonias
- 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).
15Classification 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).
16Classification 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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18Complications
- 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.
19Criteria 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.
20Criteria 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.
23Criteria 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.
24Criteria 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.
25Bronchial 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.
26Criteria 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.
28Criteria 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
29Criteria 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
30Treatment of BA
- BASIC
- Ingalation of Glucocorticoides
- Symptomatic
- B-2 agonists holinolitics
31LECTURE Nephropathies in children
- DONETSK NATIONAL MEDICAL UNIVERSITY
- Department of Paediatrics
- Chief Prof. Y.V.Prohorov
- LECTURER Asociated prof. E.A.Tolstikova
32PYELONEPHRITIS (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.
33Renal 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.
34II. 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.
35Clasification 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
36Differential diagnosis
- cystitis,
- glomerulonephritis,
- renal tuberculosis,
- renal tumor,
- urolithiasis.
- Pyelonephritis lasting for 6 mo. and longer is
regardedas chronic.
37TREATMENT 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
38Glomerulonephritis
- 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.
392) 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.
403. 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.
41Differential diagnosis
- - glomerulonephritis
- - pyelonephritis,
- - renal tuberculosis,
- - and tumor.
42CLASSIFICATION 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.
43B. 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.
44C. 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.
45Interstitial 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.
47Clinical 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.
48Acute 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.
49B. 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.
50C. Post-renal (obstructive)
- Calculus,
- blood dots,
- crystals of uric acid,
- sulphonamides.
51Stages 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
53Chronic 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.
541. 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.
55Cause 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.
56- 2. Congenital anomalies
- bilateral renal dysplasia
- Reflux nephropathy.
- Obstructive nephropathy
- pelviureteric junction obstruction
- posterior urethral valve
- calculi.
- 3. Miscellaneous
- - bilateral Wilms1 tumor.
57Dysmetabolic 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).
58Diagnostic 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.
59//. Laboratory findings
- - elevated blood and urine level
- (more than 3,9 mmol/l and 3,6 mmol/day
correspondingly) of uric acid.
60LECTURE
- CARDIOLOGYCongenital Heart Diseases
- DONETSK NATIONAL MEDICAL UNIVERSITY
- Department of Paediatrics
- Chief Prof. Y.V.Prohorov
- LECTURER Asociated prof. E.A.Tolstikova
61Patent 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.
62Diagnostic 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.
63///. 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.
64Atrial 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.
65Hemodynamics
- 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.
66Diagnostic 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.
67//. 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.
68Ventricular 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.
69Hemodynamics
- 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.
70Diagnostic 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.
71III.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.
72Coarctation 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.
73Diagnostic 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.
75Tetralogy 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.
76Hemodynamics
- 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.
77Diagnostic 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
78//. 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.
79Classification 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
80- - 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
81Without 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
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