Respiratory complaints in children Tachypnea n An abnormally

Respiratory complaints in children

Tachypnea: n An abnormally rapid rate of breathing.

Bradyapnea: n An abnormally slow rate Age of breathing. Range of normal breath/min Rapid Newborn 30 -50 More than 60 Infancy 20 -30 More than 50 Toddler 20 -30 More than 40 Children 15 -20 More than 30

Tachycardia: n An abnormal condition in which the myocardium contract regularly but at rate greater than normal.

Bradycardia: n An abnormal circulatory condition in which the myocardium contract steadily but at a rate less than normal. Age Normal Range Average (beat/min) 0 -1 months 70 -190 125 1 -11 months 80 -160 120 2 years 80 -130 110 4 years 80 -120 100 6 years 75 -115 100 6 -12 years 70 -110 90

Cyanosis: n Bluish discoloration of the skin & mucous membrane caused by an excess of deoxygenated hemoglobin in the blood or a structure defect in the hemoglobin molecule.

Grunting: n Abnormal short audible grant like breaks in exhalation that often accompany severe chest pain. The grant occurs because the glottis briefly stops the flow of air, halting the movement of the lungs & their surrounding or supporting structures.

Clubbing: n Increase in the soft tissue of the distal parts of a fingers or toes in which the extremities are broadened & the nails are shiny & abnormally curved.

Nasal flaring: n A sign of respiratory distress, reduces the resistance to inspiratory airflow through the nose & may improve ventilation.

Hypoxia: n An inadequate reduce tension of cellular oxygen characterized by cyanosis, tachycardia, hypertension, peripheral vasoconstriction, dizziness & mental confusion.

Hypercarpia: n Greater than normal amount of carbon dioxide in the blood.

Acid-base balance: n A condition existing when the net rate at which the body produces acid or bases equal the net rate at which acid or bases are excreted, the result is a stable concentration of hydrogen ion in body fluid.

Wheeze: n A form of rhonchus common characterized by a high pitched musical quality. Its caused by a high velocity flow of air through a narrowed airway, & It’s heard both during inspiration & expiration.

Stridor: n An abnormal high pitched musical respiratory sound caused by an obstruction in the trachea or larynx.

Cough: n A rapid expulsion of air from the lungs typically in order to clear the lung airways of fluids, mucus, or material.

Differential diagnosis of acute stridor at different ages: n n n n Laryngotracheobronchitis: commonly known as croup, is the most common cause of acute stridor in children, especially children aged 6 months to 2 years. Aspiration of foreign body is common in children aged 1 -2 years. Bacterial tracheitis is relatively uncommon and mainly affects children younger than 3 years. Retropharyngeal abscess is a complication of bacterial pharyngitis observed in children younger than 6 years. Peritonsillar abscess. Spasmodic croup, occurs most commonly in children aged 1 -3 years. Allergic reaction. Epiglottitis is a medical emergency occurring most commonly in children aged 2 -7 years.

Differential diagnosis of chronic stridor at different ages: n n n n n Laryngomalacia is the most common cause of inspiratory stridor in the neonatal period and early infancy. Patients with subglottic stenosis can present with inspiratory or biphasic stridor. Vocal cord dysfunction. Laryngeal dyskinesia, exercise-induced laryngomalacia, and paradoxical vocal fold motion are other neuromuscular disorders that may be considered. Laryngeal webs are caused by an incomplete recanalization of the laryngeal lumen during embryogenesis. Laryngeal cysts are a less frequent cause of stridor. Laryngeal hemangiomas (glottic or subglottic) are very rare. Laryngeal papillomas. Tracheomalacia. Tracheal stenosis.

Croup: n Mucosal inflammation & swelling by laryngeal & tracheal infection. n Can cause life-threatening airway obstruction in young children.

Croup Viral croup Bacterial croup Spasmodic or recurrent haemophilus influenzae

Viral croup… n 95%. n The commonest is Para-influenza v. n RSV & influenza. n Affect. . 6 months_ 6 years (peak at 2 years).

Pathogenesis. . n laryngeotrachiaitis Mucosal inflammation & increased Secretion. Edema that cause narrowing of the trachea. Obstruction of the airway.

Symptoms… ( worse at night) n Barking cough. n Harsh stridor. n Hoarseness. n Fever & coryza.

Clinically assessment of sever upper airway obstruction. . n Sternal & subcostal recession. n Respiratory rate. n Heart rate. n Increased agitation. n Drawsiness , tiredness , exhaustion. n Central cyanosis.

Management Basic manag. n Don’t examine throat. n Reduce the pt. anxiety. n Observe the signs of hypoxia. n Urgent tracheal intubation in case of obstruction.

n Mild croup: can managed at home. (mild obst. , stridor & chest recession disappear at rest). n Sever croup: at hospital. (sever symptom , oxygen sat. less than 93% in air). n Less than 2%: require intubation.

Cont. management. . n Inhalation of worm moist air. n Oral dexamethazone & nebulized steroids. n Nebulized adrenaline (transient improvement in sever obst. )

Spasmodic , recurrent croup n Suddenly develop braking cough , stridor at night without preceding respiratory symptoms. n Have hyper-reactive upper airway. n Some will develop other or a topic illnesses hey fever, eczema.

(Pseudomembranous croup) Bact. tracheitis. n Rare but dangerous. n Caused by staph aureus or h. influenza. n Clinical pict. Similar to sever viral croup + high fever , appear toxic. n Rapidly progressive airway obst. n Copious thick secretion found with tracheal intubation.

Acute Epiglottitis n Definition: Inflammation of supraglottic region of the oro-pharynx (epiglottis , vallecula, arytenoids, aryepiglottic folds).

Causative organisms: n 1 - Most commonly Hib n 2 - Hemophylus parainfluenzae n 3 - Strept. pneumoniae n 4 - Group A streptococcus n 5 - Staph. aureus

n n n Frequency : Generally uncommon. Increase incidence in areas that don't require mandatory Hib vaccine More common in children than in adults with a ratio of 2. 6: 1 respectively. But may occur at any age. Age : In children 1 --> 6 years adults >45 with a male predominance. 3: 1 M: F ratio. However , with the introduction of Hib vaccine in infancy, there has been a 99% decrease in incidence of epiglottitis + other Hib infections.

n Morbidity + Mortality: 1 - Airway obstruction : by inflamed epiglottis that obstructs the airway also by impaired clearance of secretions. 2 - difficulty intubating patients with extensive swelling. n adult mortality rate 7%. n child mortality rate < 1%.

Clinical picture: n n is usually acute with rapidly progressive presentations. SYMPTOMS: 1 - sore throat (95%) 2 - odynophagia / dysphagia (95%) 3 - muffled voice (54%) 4 - dyspnea 5 - usually not preceded by prodromal symptoms or coryza. There may be mild or absent cough

SIGNS: n n n n Patient looks ill, toxic and irritable. fever > 38. 5 ˚C. tachycardia and tachypnea. soft inspiratory stridor with rapidly progressing respiratory distress causing child to lean forward and hyperextend the neck to enhance air exchange. drooling and inability to handle secretions. cervical lymphadenopathy. on direct / indirect visualization of the larynx, a beefy, red, stiff and oedematous epiglottis can be seen. N. B. Attempts to lie the child down or examine throat with spatula or obtain swabs must not be undertaken as they can precipitate total airway obstruction and death

Diagnosis: n 1 -Lab studies : a- Epiglottic swab: samples for laboratory tests should not be drawn and epiglottic swab culture should not be obtained until the airway has been secured. b- Blood culture.

n 2 -Imaging studies : a- Lateral neck soft tissue x-ray is useful to confirm diagnosis (using a criteria of 7 mm thickness as being 100% specific and sensitive as the normal thickness is 3 mm). b- Chest x-ray : for visualization of endotracheal tube. Radiographic evaluation is being replaced by direct visualization by pharyngoscopy c- Naso-pharygoscopsy (diagnostic method): should be done in patients who are not distressed and when DX of epiglottitis is suspected (avoid this method until airway has been secured).

Treatment: n A- Securing the airway: according to the degree of epiglottitis severity a-In patients with severe disease (i. e. presenting with respiratory distress , stridor, inability to swallow, sitting erect and deterioration within 8 -12 hours), securing the airway is the safest method 1 - orotracheal intubaion is almost always required when there is acute airway obstruction. 2 - if intubation can not be performed, cricothyroidotomy or needle-jet insufflation are the next lines of treatment. b- Patients without signs of airway compromise may be managed without immediate airway intervention by close monitoring in the ICU.

Cont. treatment. . n n n B- Administer supplemental humidified Oxygen C- Antipyretics D- Antibiotic therapy: after blood and epiglottic cultures have been obtained, emperic coverage for group A Streptococcus pneumoniae, S. pyogenes and H influenzae should be provided ( third degree cephalosporin or amoxicillin/clavulanic acid) e. g. Ceftriaxone, Ampicillin, Choloramphenicol N. B 1: Racemic epinephrine, steroids, sedatives and Beta agonists should be avoided. N. B 2: An anaesthesiologist and ENT specialist should be notified as soon as a possible case of emergency epiglottitis or if operative management is anticipated.

Prevention: n 1 - Hib vaccine. n 2 - close contacts of patients in whom Hib has been isolated should receive Rifampin prophylaxis.

Complications: 1 - Pulmonary edema 2 - Epiglottic abscess 3 - Pneumonia 4 - Meningitis 5 - Cervical adenitis 6 - Septic arthritis 7 - Pericarditis 8 - Cellulitis 9 - Septic shock

Difference between croup and epiglottitis: Croup Epiglottitis Over days Over hours Yes No Sever, barking Absent or slight Able to drink Yes No Drooling of saliva No Yes Appearance Unwell Toxic, very ill Fever <38. 5˚C >38. 5˚C Stridor Harsh, rasping Soft, whispering Hoarse Muffled, reluctant to speak Onset Preceding coryza Cough Voice, cry

Cough What is cough? A forceful expiration that removes excess secretions, foreign body and infected material from the airway.

How does it happen? Cough may be voluntary or may be generated by reflux. Stimulation of irritant receptors in the airway mucosa: n nose, n sinus, n pharynx, IX n larynx, n trachea, X n bronchi or bronchioles. n Pleura n Pericardium and diaphragm phrenic N.

Mechanism of cough: n n During cough, person inspires deeply to 60% to 80%of TLC. The glottis closes and respiratory muscles contract leading to compression which greatly increases intra-thoracic pressure. Explosive exhalation, the glottis open suddenly. The airways are cleared by compression and high velocity exhaled gas.

Loss of reflex can be due to: n n unresponsive nerve endings, depression of cough center in brain stem, laryngeal disorders(paralysis of vocal cords), or extensive disease in peripheral airways and alveoli. ) Complications: n n leads to aspiration and pneaumonia.

HISTORY: 1) Onset 2) Duration 3) Productive 4) Time of day 5) Aggravating and alleviating factors 6) Associated wheeze or stridor 7) Associated symptoms 8) History of exposure to respiratory illness 9) Family Hx 10) Environmental history

EXAMINATION: n General look n Respiratory pattern and rate, work of breathing n Inspection n Palpation n auscultation

Caused of acute cough: n n n n URTI Acute laryngitis, tracheobronchitis Acute broncheolitis Pneumonia Bronchial asthma Foreign body Measels, pertusis Chemical irritation

Acute cough: URT n Common cold (coryza) n Acute tonsillo-pharyngitis n Acute sinusitis n Acute laryngitis n Chemical irritation n Foreign body

Common Cold n n n What? Acute viral inflammation of mucous membrane of the nose and pharynx Cause? Rhinoviruses C/P? - Low grade fever -watery nasal discharge -sneezing -cough - signs of nasal congestion - unable to breast feed in infants

Acute Tonsillo-Pharyngitis n Cause? GAßS and adenoviruses n C/P? Fever – anorexia – vomiting –dysphagia – thick voice – cough

ONSET COURSE FEVER COUGH L. N. WBCs DIARRHEA BACTERIAL sudden sever High grade late + >10, 000 Not specific VIRAL gradual mild Low grade Early Not specific <10, 000 +

Acute Sinusitis n n Usually accompanies URTI Causes? - Hypertrophied adenoids - Deformity of nasal septa - Allergy - Recurrent rhinitis C/P? - Fever -Headache - Mucopurulent nasal discharge - Post-nasal discharge - Facial tenderness

Pneumonia n Definition. n Classification. • Anatomical classification. • Etiolological classification. • Age classification. n Differential diagnosis of recurrent pneumonia.

Lobar Pneumonia n Causes. n Pathology. n Clinical manifestation. n Investigation. n Complication. n Treatment.

Bronchopneumonia n Causes. n Pathology. n Clinical manifestation. n Investigation. n Complication. n Treatment.

Viral Pneumonia n Causes. n Pathology. n Clinical manifestation. n Investigation. n Treatment.

Bronchiolitis n n n n Definition. Causes. Pathophysiology. Clinical manifestation. Investigation. Differential diagnosis. Complication & cause of death Treatment.

Cystic Fibrosis n Epidemiology & etiology n Clinical manifestations n Diagnostic studies n Treatment n Complications

Epidemiology: n The commonest cause of chronic suppurative lung disease in caucasians, and the most common life-limiting recessive genetic disease in whites. n (1 in 3200) in whites. (1 in 15, 000) in African Americans. (1 in 31, 000) in Asians.

Etiology: n n An autosomal recessive disorder. A gene mutation in chromosome 7, that codes for the protein called: cystic fibrosis transmembrane regulator- (CFTR) which is defective in CF. (CFTR) is an AMP-dependent chloride channel blocker. In CF there’s abnormal ion transport across the epithilial cells of the exocrine glands ( Resp. tract & Pancrease ), -because CFTR is defective- resulting in increased viscosity of secretions and excessive conc. Of Na+ and Cl- in the sweat (up to 80 -125 mmol/L).

Clinical Manifestations: n n n n n Malabsorption Failure to thrive Recurrent or persistent (chronic) chest infection >> chronic reproductive cough, (purulent sputum) Organisms detected: Staph. aureus, H. influenza, pseudomonas. Bronchiectasis, abscess formation. Hyperinflation of the chest due to air trapping, coarse crepitations or expiratory ronchi. Finger clubbing. In infants : 10 -20 %> meconium ileus> signs of intestinal obstruction, failure to pass meconium. Steatorrhea < pancreatic enzymes insufficiency (lipases, amylases, proteases)

Diagnostic Studies: Sweat Test Sweating is stimulated by pilocarpin iontophoresis, and sweat is collected. Two tests with an adequate volume of sweat should be performed by experienced staff to diagnose CF

Treatment: n Carried out by a multidisciplinary team approach, including: pediatricians, physiotherapists, nursing staff, dieticians, the primary care team, and teachers. n The condition cannot be cured (so far). n The aims of treatment are to prevent the progression of the lung disease and to maintain adequate nutrition and growth.

n Causes of death in CF Progressive bronchiectasis and respiratory failure.

Complications: n Respiratory. n Gastro-intestinal. n Others.

Wheezing Definition and Physiology of wheezing: n n A wheeze is a continuous musical sound heard during chest auscultation that lasts longer than 250 msec. It is produced by the oscillation of opposing walls of a narrowed airway narrowed almost to the point of closure. It can be high-pitched or low-pitched, consist of single or multiple notes and occur during inspiration or expiration. Wheezing can originate from airways of any size, from the large extra-thoracic upper airway to the intrathoracic small airways. In addition to narrowing or compression of the airway, wheezing requires sufficient airflow to generate airway oscillation and produce sound.

Cont. physiology: Wheezing caused by a large or central airway obstruction has a constant acoustical character throughout the lung, but varies in loudness depending upon the distance from the site of obstruction. It is referred to as monophonic (or homophonous) wheezing. In the setting of small airway obstruction, the degree of narrowing varies from place to place within the lung. As a result, the sounds generated also vary in quality and acoustical character and are described as polyphonic ( or heterophonous) wheezing.

Clinical manifestations: History: n n Number and frequency of wheezing episodes. The relationship of the episodes to viral infection or aeroallergen exposure. The presence of allergic disease such as conjunctivitis, rhinitis or/and eczema. The parental Hx of asthma.

Physical examination: n n n The overall appearance of the child (respiratory distress and work of breathing). Whethere’s wheezing, transmitted upper airway nasal congestion, stridor and wheezing, or wheezing and crackles. The location of wheezing ( unilateral, suggestive of a foreign body or bronchomalacia, or bilateral, suggestive of a more generalized process. The child’s growth curve. Clinical features such as rhinitis and/or conjunctivitis and the presence of eczema. The presence of a central or midline structural or cutaneous lesion such as hemangioma ( associated with an increased risk of an intrathoracic lesion).

Differential diagnosis: 1 - Infection: VIRAL: RSV, para-influenza, Adenovirus, influenza and Rhinovirus. OTHERS: Chlamydia trachomatis, Tuberculosis and Histoplasmosis. 2 - Bronchitis. 3 - Laryngeotracheobronchitis 4 - Bacterial tracheitis 5 - Asthma. 6 - Anatomic abnormalities: Central, extrinsic and intrinsic airway abnormaleties. Congenital heart disease with left-to-right shunt ( increased pulmonary edema). 7 - Inherited. 8 - Bronchopulmonary dysplasia. 9 - Aspiration syndrome ( GERD). 10 - Interstitial lung disease including bronchiolitis obliterans. 11 - Foreign body.

Recurrent Wheeze Age infant/ child n Symptoms reversible/ not n Hx of chest infection bronchiolitis, bronchectasis… n Associated symptom allergies, stridor, vomiting and choking, n Hoarseness, growth failure. n

Differential Diagnosis of Recurrent Wheeze: Structural abnormalities Tracheo-bronchomalacia Vascular compression/ rings Tracheal stenosis/webs Cystic lesions/masses Tumors/lymphadenopathy Cardiomegaly Functional abnormalities Asthma Gastro-esophageal reflux Recurrent aspiration Cystic fibrosis Immunodeficiency Primary ciliary dyskinesia Bronchopulmonary dysplasia Retained foreign body Bronchiolitis obliterans Pulmonary edema Vocal cord dysfunction

It’s paroxysmal attacks of cough, dyspnea and wheezes. What is Asthma? n n Caused by generalized obstruction of the airways due to bronchial hyper-reactivity. To a variety of stimuli. Associated w high degree of reversibility of the obstruction either spontaneously or with treatment.

Precipitating Factors: n n n n URTI viral… Allergens house dust mite, pollens, mold, animal feathers… Smoking passive/ active. Changes in temperature. Exercise. Emotional changes. Chemicals paints, aerosoles, fumes…

Diagnosis of Asthma: n n n • • Is established according to Hx and Ex Clinical Presentation Hx Age 50% < 2 y / 80 -90% < 4 or 5 y. Symptoms cough (non productive). wheeze. dyspnea/ chest tightening. associated symptom allergic rhinitis, conjunctivitis, eczema or food/drug allergy. Onset, progression, frequency, reversibility of symptom, condition of pt btw attacks. Precipitating & aggravating factors. Past recurrent chest infection pneumonia, bronchitis, bronchiolitis… Family Hx asthma or allergy. Social Hx pets at home, smokers.

Examination n General pt dyspnic, RR rapid + prolonged expiration, alae nasi. Use of accessory muscles. Irritability, sweating or cyanosis. n Inspection pallor. chest deformity. hyperinflation. n Palpation. Percussion. n n Auscultation: -decreased air entry. -vesicular breathing with prolonged expiration. -wheeze

Severity of Asthma: Intermittent Mild persistent Moderate persistent Severe persistent Frequency < 2/ wk 2< /w daily Daily &Cont PF FEV/PEF Norm btw attacks <80% 60 -80% <60% Attacks Brief hrs-ds Affects activity 2/w days Limits activity Night cough <2/ m 2</m 1</w Frequent daily PEF var <20% 20 -30% 30%<

Classification of Acute Attacks of Asthma According to Severity Mild Moderate Severe Dyspnea -No/mild -Can lie down -Speaks in sentences -Moderate -Prefers sitting -severe at rest -sits upright -words Alertness May be agitated Usually agitated Agitated, drowsy confused RR Slight 30 -50%< Intercostal Retraction No/mild moderate+ substenala, subcostal retraction Like mod+ nasal flaring +chest hyperinflation Color Normal Pale May be cyanotic Ausclt End exp wheeze Insp + exp wheeze Inaudible BS PEFR 70 -90% 50 -70% <50 O 2 saturation >95% 90 -95% <90%

In Status Asthmaticus, wheeze might be absent!

Investigations: n n n Blood leukocytosis, eosinophilia ABG p. O 2 p. CO 2 p. H Immunology evaluation Ig. E Ab titers CXR hyperinflation, cong heart ds. PFM children 5< y to ht/wt

Management: n Short Acting Bronchodilators (relievers): * Salbutamol, terbutaline inhalers. n • • • Prophylactic Therapy (preventers): Steroids. Na cromoglicate. Long acting B 2 agonists. Slow release oral theophylline. Leukotrien modulators. Antihistamine.

ARTERIAL BLOOD GASES n n An arterial blood gas test is a blood test to measure how well the body uses oxygen and gets rid of carbon dioxide. It also measures the acidity, or p. H of the blood. The blood for this test is drawn from an artery. An artery is oxygen-rich blood from the heart and lungs to the rest of the body. Arteries run deeper under the skin than veins. For this reason, drawing blood from them is a little more difficult and uncomfortable. Even so, the entire procedure lasts only a few minutes.

n n The artery most commonly used for this test is the radial artery in the wrist where your pulse is usually checked also we can take a sample from the brachial artery. Since blood pressure is stronger in arteries than in veins, the puncture may take longer to close. Firm pressure is applied to the site for 5 to 10 minutes following the test. A bandage is applied and you should rest quietly for an additional 15 minutes. The blood is evaluated in the laboratory immediately to get the most accurate results. An arterial blood gas may be requested to evaluate respiratory disease or conditions that affect the lungs. It is also used to check how well oxygen therapy or other breathing treatments are working. An abnormal result may mean that your body is not getting enough oxygen, not getting rid of enough carbon dioxide, OR that something is wrong with the way the kidneys are working.

Precautions according blood sampling n Anticoagulant ‘’heparin’’ in the syringe. n Make sure no air bubbles in the syringe. n Transport it immediately to the lab.

What does the Blood gas analyzer measure? n It measures the PCO 2, Po 2 & [H+] directly, while [ HCO 3 -] is calculated.

Analyte Range Interperation PH 7. 35 – 7. 45 The p. H or H+ indicates if a patient is acidotic (p. H < 7. 35; H+ >45) or alkalotic (p. H > 7. 45; H+ < 35). H+ 35 – 45 nmol/l p. O 2 75 – 100 mm. Hg Values below 60 may require immediate action and possibly mechanical ventillation. p. CO 2 35 – 45 mm. Hg (PCO 2) indicates a respiratory problem: for a constant metabolic rate, the PCO 2 is determined entirely by ventilation. [1] A high PCO 2 (respiratory acidosis) indicates underventilation, a low PCO 2 (respiratory alkalosis) hyper- or overventilation. HCO 3 - 22 – 30 mmol/l The HCO 3 - ion or base excess indicates whether a metabolic problem is present (such as ketoacidosis). A low HCO 3 - or negative base excess indicates metabolic acidosis, a high HCO 3 - or high positive base excess, metabolic alkalosis.

Respiratory disorder n In respiratory acid-base disorders , the primary disturbance is caused by changes in the arterial blood PCO 2. n Even in ventilation or gas exchange.

Respiratory acidosis n High [H+] n Low PH n High Pco 2 n Slight high [HCO 3 -]

Respiratory Acidosis: n n n Acute & chronic. Acute: is caused by alveolar hypoventilation by parially or compeletly reduced airflow that’s leads to low PO 2 & high PCO 2 (medical emergency). Causes: choking , bronchopneumonia & acute attacks of asthma.

n In choric there is a renal compensation BY increasing the execrtion of hydrogen ion & increase the bicarbonate level ( twice) in ECF giving a normal blood [H+] level n Causes: chronic bronchitis, emphysema.

Causes of respiratory acidosis: n Airway obstruction: Chronic obstructive airway disease, e. g. bronchitis , emphysema. Brnochospasm, e. g. in asthma. Aspiration. n Pulmonary disease: Pulmonary fibrosis. Severe pneumonia. Respiratory distress syndrome. n Depression of respiratory centre: Anaesthetics. Sedative. Cerebral trauma. Tumors.

Respiratory Alkalosis n Less n n common than respiratory acidosis Low [H+] High PH Low Pco 2 Slight low [HCO 3 -]

Causes of respiratory alkalosis: n Hypoxia: High altitude. Severe anemia. Pulmonary disease. n Pulmonary disease: Pulmonary edema. Pulmonary embolism. n Increased respiratory drive: Respiratory stimulant, e. g. salicylates. Hepatic failure. Primary hyperventilation syndrome. n Mechanical overventilation.

Diagnosis: n History. n Arterial blood gases. n Biochemical measures.

Management of acid-base disorders: n • • • According to the underline cause: In diabetic ketoacidosis give fluids & insulin. Artificial ventilation in status asthmaticus. Restoring the blood volume in cases of hemorrhage.

Thank you Group E 1