Acute Bronchiolotis.pptx
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Acute Bronchiolotis Clinical Case Frank is a 12 month old boy who presented to the Emergency Paediatric Unit of MUTH with a three-day history of cough, fever, and noisy breathing that is worse at night. He suckles well at the breast and his mum also gives him infant formula and water. He at...
Acute Bronchiolotis Clinical Case Frank is a 12 month old boy who presented to the Emergency Paediatric Unit of MUTH with a three-day history of cough, fever, and noisy breathing that is worse at night. He suckles well at the breast and his mum also gives him infant formula and water. He attends day care and sometimes stays with his grand mum who also coughs. There is no family history of asthma. On examination, he weighed 10kg and no pedal oedema was observed. His temperature was 37.5oC, RR 68cy/min, intercostal recession, and rhonchi . QUESTION. What is the most likely diagnosis?. Introduction It results from inflammatory injury of the bronchioles. It occurs during the first 2 years of life. It is predominantly a viral disease Aetiology Respiratory syncytial virus (RSV) 50% -75 % of cases. Parainfluenza viruses especially type 3 Adenoviruses Rhinovirus Chlamydia pneumonia Mycoplasma. Human Meta pneumovirus Human Bocavirus NOTE: There is no evidence of a bacterial cause for bronchiolitis, although bacterial pneumonia is sometimes confused clinically with bronchiolitis EPIDEMIOLOGIC RISK FACTORS Age : Common in children under 2 years of age. Gender : commoner in Males 2:1 Breast feeding: Common in children who were not exclusively breastfeed. Seasonal Factors: common during the rainy season and cold harmattan months. Exposure to cigarette smoke Babies who attend day care centres. Babies living in crowded conditions Pathophysiology Viral infection of the distal bronchi and bronchioles causes mucous secretion, necrosis of the respiratory epithelium, and oedema of bronchiolar mucosa. This leads to a reduction in the size of the lumen of bronchioles, with subsequent resistance to flow of air . If the obstruction is complete, athelectasis results. If incomplete, there is air trapping and hyperinflation Pathophysiology There will be impairment of normal gaseous exchange at the alveolar level, this causes a ventilation perfusion mismatch and gives rise to hypoxaemia early in the disease and hypercapnia later. Clinical features It is usually preceded by exposure to an older contact with a minor respiratory syndrome within the previous week. Infants are affected most often because of their small airways. Episodic or paroxysmal cough Poor feeding/ refusal to feed Wheezing (Wheezing, the production of a musical and continuous sound that originates from oscillations in narrowed airways, is heard mostly on as a result of critical Clinical features Chest retraction Fever which is usually low grade. Grunting Cyanosis Hyperresonant percussion notes Reduced breath sounds Prolonged expiratory rhonchi Fine crepitations Palpable non tender Liver due to descent of diaphragm Investigations FBC ( not diagnostic, WBC and differential counts are usually normal) CXR ( shows patchy atelectasis with hyper inflated areas.)CXR should not be routinely requested for Arterial Blood Gas. Pulse oximetry Rapid viral antigen or nucleic acid amplification testing of nasal or pulmonary secretions. Differential diagnosis Bronchial Asthma (recurrent attacks, positive family hx, eosinophilia in blood. ) Bacterial bronchopneumonia ( high grade fever, no rhonchi except in severe illness, coarse creps.) Pertussis Foreign GERD body aspiration treatment Management is essentially supportive. Hypoxemic children should receive humidified oxygen Adequate fluid and calories Nebulised hypertonic saline Antibiotics for secondary infection. Ribavarin given by nebulization. Use of corticosteroids is controversial…… Combined therapy with nebulized epinephrine and dexamethasone has been used with some success Trial of bronchodilator therapy Prophylaxis Periodic passive immunoprophylaxis with RSV monoclonal antibody ( Palivisumab) Protection of other children/ preventing child – to- child transmission, e.g in hospitals, day care. Prognosis Prognosis is generally good. The most critical period is the first 48-72 hours . The case fatality rate is <1%, with death attributable to apnea, respiratory arrest, severe dehydration QUESTION Concerning Bronchiolitis a) It is a known cause of paroxysmal cough in children b) It is predominantly caused by viruses C) Percussion note is dull d) There is bronchospasm e) Nebulized dexamethasone is beneficial in the treatment In managing a patient with bronchiolitis, therapies to consider include which of the following? Bronchodilator therapy Intranasal oxygen. Intravenous fluids Chromoglycate sodium Nasal suctioning. Which of the following may offer passive prophylaxis for bronchiolitis Air purifiers Ribavarin Palivizumab Prednisolone. Salbutamol
