pediatric respiratory cases€¦ · treatment • bacterial pneumoniea ;mild ,out-patient mx :oral...
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PediatricRespiratorycases
DrEnas AlZayadnehPediatricPulmonologist
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Case 1
Hx
Mohammad,
4montholdinfant,presentedwithcough ,wheezefor3days.HxofURTI2dayspriortoonsetofsymptoms.
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Question1
1-Whatareimportantquestionsyoushouldaskinhistory?
Mentionanythingrelevantin:HOI,ROS,Pastmedical,Birth,Social,Vaccination,drughx
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Q1:Answeranddiscussion
Seenotesbelow
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Question2
-Whatareimportantfindingsyoushouldlook forinPhysicalExamination?Pleaseobservethefindingsinvideobelowhttps://www.youtube.com/watch?v=QNrsjDzD0
-QM
Kindly0bservenotesbelow
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Question3
Whatimportantinvestigationsshouldbeperformedforthischild?
Kindlyobservenotesbelow
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Q4:whatisyourinterpretation?
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WhatisyourDDxlikelydiagnosis
Acuteviralbronchiolitis
Viralbronchopneumonia
Bacterialpneumonia
Reactiveairwaydisease
AspirationPneumonia
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Whatisyourdiagnosis?
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Acuteviralbronchiolitis
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ACUTEViralBRONCHIOLITIS
• Commondiseaseofthelowerrespiratorytracrininfants.usually mostcases<2years.
• Inflammatoryobstructionofsmallairways.• Severediseasemoreininfants1-3monthsofage.
• Seasonalpeakinwinter-earlyspring.• Mostcommonvirus;RSV
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Treatment• Primarilysupportive
• Hospitalization,forchildrenwithrespiratorydistress
• Ifhypoxic(coolhumidifiedoxygen).childsittingwithheadandchestelevated30degreeanglewithneckextended.
• Hydration:IVF,NGfeeds
• SymptomaticTx:nebulizationwithNormalsaline/Hypertonicsaline
• Ifworseningrespiratorydistress,persistent hypoxemia;considerpositivepressureventilationCPAP
• Forpendingrespiratoryfailure,respiratory failurewithacidosismapnea:considerintuabtion andassistedventilation
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Case2
Hx :6yearsold,previouslyhealthy.Presentedtoclinicwithfever for5days,reaching39.5C.Associatedwithcoughintermittent.Hismothernotedrapidbreathinganddyspneaworseningwithtime.HadhxofURTI1weekago.Hisappetiteandactivitydecreased.Vomited twice
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P/E :General:looksunwell,hasincreasedWOB.(RR40b/m,PR 110,temp39).subcostalandintercostalretractions.Chest:Auscultation:decreasedairentryonRtlowerside.Bronchialbreathing,increasedtactilevocalfremitus,fewinspiratorycracklesRtside.Percussion::dulltopercussion
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WhatareClinicalInvestigationsneeded?
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CXRCBC,Bloodculture,inflammatory
markers,…etc
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•
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Whatisyourdiagnosis?
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Pneumonia
specific:(lobar,bacterial)
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PneumoniaDefinition
Inflammationoftheparynchyma ofthelungs.(alveoliandterminalairspacesinresponsetoinvasionbyaninfectiousagentintroducedintothelungsthroughhematogenousspreadorinhalation)
Causes:Infectious,mostly(Strept Pneumonia,staphaureus,Mycoplasmap.Noninfectious:
aspirationoffoodorgastricjuicehypersensitivityreactionsforeignbodies
Hydrocarbonsandlipoidsubstancesradiationinducedpneumonitis
•
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COMPLICATIONS• Pleuraleffusion
• Directinvasion:Empyema,pericarditis
• Hematogenous spread:Meningitis,supporativearthritisandosteomyelitis (rare).
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Complicatedpneumonia
PleuraleffusionNecrotizingpneumonia:
cavitaion
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TREATMENT• Bacterial pneumoniea ;mild ,out-patient Mx :oral
amoxicillin ,cefuroxime, amoxicillin/clav. • School-aged children (Mycolpasma pneumoniea)
macrolide like azithromycin.• Sick ,hospitalised patients ;parenteral cefuroxime .if
staph. aureus suspected (pneumatocele ,empyema) clindamycin or vancomycin .
• Viral pneumoniea ,if mild no respitatory disress no need for AB therapy , 30% of cases have co-existing bacterial infx. Clinical status to decide use of AB for superimposed bacterial infx,
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Case3• Hx:
• 12yearoldchild,presentedtotheclinicwithhx ofcoughfor7daysduration.Cough(dry,worseatnightandpostexercise,asswithwhistlingsound),symptomsstartedfollowingarecentURTI).itworsenedoverlast2dayswithdyspnea attimes.
• PastHx :previousepisodesoccurringmostlyduringwinter,hashayfever,hadeczemaduringearlychildhood.Positivefamilyhxofsimilarcondition.
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P/E :Afebrile ,RR 35 (20-30) ,
Pulse rate 100 .SPO2 89%.ENT :Hyperemic throat.Intercostal and subcostal retractions .Chest :diffuse Expiratory wheeze,prolonged expiratory phase with decreased air entry . CVS :normal ,liver not palpable , hands : no finger clubbing .
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Question 1
1-What are important questions you should ask in history ?Mention anything relevant in :HOI,ROS,Past medical ,Birth ,Social , Vaccination, drug hx
For discussion see notes below
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Question 2
-What are important findings you should look for in Physical Examination ?
Please observe video below ,
https://www.bing.com/videos/search?q=video+physical+examination+for+a+child+with+asthma&&view=detail&mid=1716B617D91DA36B8E271716B617D91DA36B8E27&rvsmid=25C76EB9BD41A07D6EE925C76EB9BD41A07D6EE9&FORM=VDRVRV
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The following are signs found in this child can you comment
?
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Q 3 : what is you DDX
What is your DDX What is the most likely DxExplain ,discuss
See notes ,discussion below
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DDX
Bronchial asthmaCystic FibrosisPrimary ciliary dyskinesiaGERDForeign body aspiration
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What is your diagnosis ?
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Bronchial Asthma
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Why Asthma
Typical signs and symptoms ,repeated previous episodes ,seasonal variation ,presence of atopy and family history
spiromerty ,chest xray findings …etc
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Question 3
What important investigation should be performed for this child ?
See notes/discussion below
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CXR
•Usually non is needed , to review old chart and previous imaging if available .
•If child in severe distress, suspect complication or other DDx needs to be excluded .
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This is the child's CXR ,what is your interpretation ?
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SPT to common inhaled allergens
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This is a flow volume loop for this child ,what is your interpretation ?
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Question 4
•What treatment should this child receive ?•Discuss
•See notes below
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Teratment
1-Acute settings :O2 100 %for hypoxemia and respiratory distress Rapid-acting beta2-agonists as needed for symptomsShort course of systemic steroidsIpratropium Bromide nebulized
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Treatment
2-For control ,and prevention of future episodes :
1.ICS inhaled corticosteroids : first choice in children 2.LTRA leukotreine receptor antagonists 3.Combination LABA/ICS Long -acting b agonists 4.Cromolyn/Nedocromil5.Methylxanthines:Theophylline6.Syetemic steroids
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Methods of inhaled medications delivery options
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THANK YOU