Dr.Sivaramakrishnan
PICU
KKCTH
CASE 1
11/2 year old female child
Known wheezer on intermittent bronchodilators
Admitted with h/o cough for 2 days
Increased work of breathing for 1 day
Afebrile/sick looking
Severe respiratory distress (RR=80/min)
Bilateral wheeze/SCR/ICR/SSR
INVESTIGATIONS
Mild anaemia / leucocytosis / negative CRP
Normal RFT
IN ER
CXRay showed
bilateral increased
BVM
With haziness in
left lower zone
Child continuously nebulised
IV hydrocort/MgSO4/sc terbutaline given
Wheeze persisted
Distress worsened – shifted to PICU
Nebulization's continued
Child worsened further - intubated
ABG –PH-7.16/PCO2-86/PO2-179/HCO3-30/SPO2-
99%
Terbutaline & MgSO4 infusions started
Did not improve despite various ventilator
manipulations
CX-RAY
Child
worsened
further
ICD placed
Repeat X-Ray:
No improvement
PH-6.8 /PCO2-
199
/PO2-51
/HCO3-34
/SPO2-54%
FOREIGN BODY versus recalcitrant asthma
BRONCHOSCOPY PLANNED
BINGO
BRONCHOSCOPY
FOREIGN BODY
in rt. Main
bronchus
CULPRIT-thoor
dal
Edema of
bronchial
mucosa seen &
purulent
secretions
suctioned out
Dramatic improvement
ABG-PH-7.4/PO2-84/PCO2-48/HCO3-29/SPO2-
97%
Infusions gradually tapered off
Nebulisations frequency decreased
Extubated on 5th day of ICU stay
Unremarkable post extubation ICU stay
Post
extubation
Post ICU stay
2 yr old male child
Known wheezer since early infancy
Admitted with h/o cough 4 days
Increased work of breathing & fever 2 days
No H/S/O FB aspiration
On intermittent nebulisations
Irritable/sick looking
Tachypnoeic (RR-54/min)
Febrile/haemodynamically stable
B/L extensive wheeze
continuosly nebulised
IV hydrocort/mgso4/sc terbutaline given
INVESTIGATIONS
N counts with mild anemia/positive CRP
Normal liver enzymes & RFT
CX-RAY IN ER
Due to worsening
distress shifted to PICU
Child had persistent wheezing
O/E: sick,very irritable , tachypnoeic
ICR/SCR/SSR
Decreased breath sounds in LT
B/L crackles & wheeze
Nebulisations continued
Hydrocortisone continued
Following day
Marginal
improvement
Cont to be tachypneic
Cxray rpt
BRONCHOSCOPY
LT bronchial system:both lingula & UL bronchi are
filled with mucus cast suggesting PLASTIC
BRONCHITIS
RT bronchial system normal
Thorough bronchial lavage done
Cast removed by repeated saline wash
BRONCHIAL
CAST
Child improved dramatically
Nebulisations decreased
N acetyl cysteine nebulisations added
Steroids continued
Wheezing settled
Child shifted out next day for further care
POST
BRONCHOSCOPY
In HDU had resp
distress again , urgent
bronchoscopy done
again revealed a cast
similar to the first one -
removed intoto and
thorough lavage given.
Improved and shifted
to ward.
Child discharged on inhaled bronchodilators
Reviewed 1 week later
No symptoms of recurrence
Doing well
Formation of obstructive bronchial plugs or casts of
thick, tenacious mucus associated with involvement
of one or more lobes or even associated entire lung
may collapse.
FIBRINOUS/PSEUDOMEMBRANOUS/HOFFMAN’S
BRONCHIAL CROUP
First described as early as 1902
AGE – affects all ages
Youngest reported being 3 wks
PRECIPITATING FACTORS – commonly associated
with hyper reactive airway disease (asthma ,
pneumonia), cystic fibrosis , bronchiectasis ,
chronic bronchitis , inhalation of aeroallergens ,
CHD , bronchopulmonary aspergillosis or may
sometimes be IDIOPATHIC
MODERATE INFLAMMATORY CHANGES in
bronchial wall – most constantly associated.
May include congestion and edema of bronchial
wall or sometimes haemorrage and infiltration by
polymorphonuclear leukocytes , eosinophils or
lymphocytes
Signs of infection (fever , cough , dyspnea etc)
h/s/o underlying disease often present
wheeze –localised or bilateral
Decreased air entry in collapsed side
Resp distress
Adults – sometimes cough out cast
Mimics FB/status asthmaticus
CX-RAY – one or more areas of collapse
No predilection to any part of lung
Recurrent attacks may lead to fibrosis &
bronchiectasis
BRONCHOSCOPY – diagnostic and therapeutic
Cylindrical / adherent to bronchial wall
Pale grayish or greenish white
Peculiarly tough & viscid with smooth surface
2 types of cast
INFLAMMATORY : made up of fibrin & esonophil
infiltrates. Usually in underlying bronchial disease
ACELLULAR : mainly mucin with little fibrin, no
inflammatory infiltrates. Usually in CHD
SEER ET AL.
MUCUS PLUG PLASTIC BRONCHITIS
Small plugs
Causes segmental collapse
Not very tight
Can be expectorated
Large plugs
Collapse of entire
lobe/lung
Tightly adherent
Retained rather than
expectorated
Beta agonists
Steroids – beneficial but yet uncertain
NAC (breaks disulfide bonds in mucin thus lowering their viscosity)
Aerosolised urokinase / heparin have been tried
Aerosolised tPA (fibrin enhanced conversion of plasminogen to plasmin which initiates local fibrinolysis. Used in casts with high fibrin content. No definitive data, so can be tried in refractory cases)
Chest physiotherapy
BRONCHOSCOPY
FOLLOW UP
Recurrence very common
No strict pattern of recurrence
No preventive therapy
Bronchoscopy immediately if child comes with
recurrence
PROGNOSIS
good
ALL THAT WHEEZES IS NOT ASTHMA
High index of suspicion to any child presenting with
acute respiratory distress with wheeze refractory to
conventional medical therapy with unusual
radiographic picture – consider BRONCH SCOPY
sleigh johnson & E.G sita lumsden THORAX 1960
J.Y park,A.A elshemi EUR.RESPIR J,1996
John m.costeldo,david steinhom,PEDIATRICS
2002
D.Vijayasekaran,N.G.gowrishankar IP 2004
THANK YOU