bronchiolitis, croup

33
SECTION 1 ACUTE BRONCHIOLITIS

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Page 1: Bronchiolitis, croup

SECTION 1

ACUTE BRONCHIOLITIS

Page 2: Bronchiolitis, croup

IntroductionCommon disease of lower

respiratory tract in infantsCommon age group: 1-3

monthsCommon during winter

Page 3: Bronchiolitis, croup

Etiology Viral RSV - >50% Para influenza 1,2,3Adeno virus

Non-viralMycoplasma

No bacterial etiology

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Epidemiology 100,000-126,000 children

<1 yr - hospitalized annually in the US because of RSV infection

Males – non breast fed babies

Older family members (LRTI) – common source

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Pathophysiology

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Pathophysiology Bronchiolar obstructionMinor bronchial wall

thickeningResistance α

Air trapping & overinflation Atelectasis

1

radius4

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Clinical featuresHappy wheezerPreceded by URTI, Mild to

mod. fever(101-2°F)Gradual onset of wheezy

cough, dyspneaTachypnea interfere feeds,

apnea in very young infants

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Wheezy cough

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Clinical featuresPhysical examinationsTachypnea doesn’t correlate

to the lung findingsIncreased work of breathingHyperinflated chestPredominant wheezePalpable liver & spleen

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Bronchiolitis

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Investigations Chest – X – Ray:Hyperinflated lungs with

patchy atelectasis

Flat diaphragm

Increased peri-hilar bronchovascular markings

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Investigations WBC count: Normal

(without lymphopenia) Diagnosis:Healthy infant first t ime

wheeze during winter

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Differential diagnosis

Bronchial asthma- family history atopy

CCF- suck rest suck cycleFB aspiration- sudden

onset, choking episodeBacterial pneumonia- sick

child

Page 15: Bronchiolitis, croup

Course & PrognosisHighest risk (cough &

dyspnea) – first 48 to 72 hrsDeath is due to Uncompensated respiratory

acidosisApneaSevere dehydration

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Course & PrognosisRisk factors for severe

disease- age <12 wk, preterm birth, or underlying comorbidity such as cardiovascular, pulmonary, neurologic, or immunologic disease

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TreatmentHospitalize - hypoxia,

inability to take oral feedings, apnea, extreme tachypnea

Supportive therapy- IV fluids, humidified oxygen, careful monitoring

No sedation- clear upper airways

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Treatment options available

1. Inhaled epinephrine: some clinical improvement

2. Inhaled bronchodilators – no use

3. Inhaled anti-cholinergics- no use

4. Hypertonic saline nebulization- some clinical improvement

5. Steroids- No role

6. Antibiotics – no role, Mycoplasma suspected- Macrolides

7. Antiviral- Palivizumab, Ribavirin- underlying CHD, immunodeficiency

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Prevention Meticulous hand washing

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STRIDOR AND ALTB

Section 2

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StridorHarsh, high-pitched

respiratory sound, which is usually inspiratory but can be biphasic- sign of upper airway obstruction

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Causes Acute Onset

ALTB

Epiglottitis

Foreign body

Retropharyngeal abscess

Bacterial trachiitis

Peritonsillar abscess

ChronicVascular ring

Laryngomalacia

Vocal cord dysfunction

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ALTB Causes- Viruses-

Parainfluenza virus 1,2,3Inflammation of Larynx,

trachea and bronchus

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C/F Upper respiratory tract infection-

rhinorrhea, pharyngitis, mild cough, and low-grade fever for 1-3 days

Characteristic “barking” cough, hoarseness, and inspiratory stridor- worse at night and often recur with decreasing intensity for several days and resolve completely within a week

Agitation and crying- aggravate Not ill looking

Page 25: Bronchiolitis, croup

Croup

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Investigations X ray- Steeple signCroup is a clinical

diagnosis and does not require a radiograph of the neck

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Steeple sign

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TreatmentNebulized Adrenaline- moderate or

severe croup- used as often as every 20 min

Oral dexamethasone used a single dose of 0.6 mg/kg, a dose as low as 0.15 mg/kg may be just as effective

Intramuscular dexamethasone and nebulized budesonide have an equivalent clinical effect

Page 29: Bronchiolitis, croup

Complications 15% children with croup- complications Hypoxia and low oxygen saturation only

when complete airway obstruction imminent

Child who is hypoxic, cyanotic, pale, or obtunded- immediate airway management

Bacterial tracheitis in some

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EpiglottitisBends

forwardTripod

positionDroolingToxic child

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Epiglottitis

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Thumb sign

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Croup vs epiglottitis

Inflammation of LTB- Caused by virus- Parainfluenza

Usually mild No fever at

presentation- non toxic child

X ray neck AP- Steeple sign

Treatment- Nebulized adrenaline, Steroids, humidified oxygen

Inflammation of epiuglottis- Caused by bacteria- H.influenzae

Serious illness High fever at

presentation- toxic child

X ray neck lateral- Thumb sign

Treatment- may need airway management, ventilation, Antibiotics