pedia case 3.1. acute bronchiolitis

8/16/2019 PEDIA Case 3.1. Acute Bronchiolitis

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Pediatrics 2: Ward Case

#4

Nicer, Stefi Diane

Olarte, Carla Mae

Palatino, John Paul

Pangan, Kimberly Anne

Pangilinan, Mary JunevePascua, Krinzel Mae

Perez, William

Pescante, Nina Carmela


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GENERAL DATA

Informant: Mother of patient

Reliability: 90%


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GENERAL DATA

• C.M.

• 1 month and 3 weeks old

• Female

•Birthdate: August. 30, 2014

• Birthplace: lying-in clinic Dasmarinas, Cavite

• 1st admission at OMMC

• Date of admission: October 8, 2014

• Time of admission: 11:00 pm


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CHIEF COMPLAINT

DIFFICULTY OFBREATHING


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HISTORY OF PRESENT ILLNESS


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2 WEEKS PTA

• Patient had colds with a clear nasal discharge.

• Medical consult was done in the lying-in clinic

– phenylephrine HCl, chlorphenamine maleate

(Disudrin)

– 0.3 mL every 6 hours with afforded relief in 2 days

• No other associated symptoms like fever,

cough, chills, change in appetite were note.

• Patient was apparently well until 3 days PTA


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3 DAYS PTA

• Patient had productive cough of yellowishsputum accompanied by colds

• Patient was irritable and cannot be easily

pacified.• Weight loss noted as described by mother.

• Same medication, frequency and dosage wastaken

• No other accompanying symptoms. No consultwas done.


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DAY OF ADMISSION

• Patient’s condition persisted and mother noticed

difficulty of breathing described as effortful and

• Patient was referred to OMMC, hence the

admission and slower than usual.

• Presence of grunting, subcostal retractions and

alar flaring were noted.

• Patient was irritable and has a weak cry

• Patient was brought to OMMC, hence admission.


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REVIEW OF SYSTEMS


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REVIEW OF SYSTEMS

Skin (+) skin rashes (-) color change (-) changes in nails

(-) lumps

Head (-) trauma

Eyes (-) excessive lacrimation (-)redness

Ears (-) discharge

Nose (-) epistaxis

Mouth and Throat (-) bleeding gums


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REVIEW OF SYSTEMS

Gastrointestinal (+)posttussive vomiting (-)diarrhea (-)constipation

(-)hematochezia (-)melena

Genitourinary (-) gross hematuria (-) dyscharge (-)genital swelling

Hematologic (-) easy bruising

Endocrine (-) excessive sweating

Nervous/

behavioral

(-) paralysis (-) convulsion

Musculoskeletal (-) stiffness


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PERSONAL HISTORY


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A. Gestational History

• 27 years old with OB index of G3P2 (2-0-0-2)

when the patient was being conceived.

• no complications throughout the course of

pregnancy.

• In good health, and denied intake of any drugs

during the time of conception.

• Duration of gestation: 9 months (37 weeks).


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• OB index: G3P3 (3003)

Birthdate Place Manner of

Delivery

Attendant Sex Status

1 08/9/08 Lying in

clinic in

Dasma

NSD Doctor M No

reported

diseases

2 10/14/10 Lying in

clinic in

Dasma

NSD Doctor M No

reported

diseases

3 08/30/14 Lying in

clinic in

Dasma

NSD Doctor F Curently in

the hospital


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B. Birth History

• Term

• via NSD

•

in a lying-in clinic in Damarinas City, Cavite• attended by a physician.

• Birth weight at birth: 3.2 kg

• born as a well-baby.


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C. Neonatal History

• no complications upon delivery

• good cry

•

spontaneous respiration• no cyanosis, pallor, nor jaundice.

• no convulsions, hemorrhage, congenital

abnormalities, nor birth injury.


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D. Feeding History

• breastfed most of the time

• given formula milk ~once a week, whenever

the mother has to go somewhere leaving the

patient behind.

• 9x/day

• 12 minutes in each breast/about 24 minutes

per session.

• Ascorbic acid and multivitamins (Tiki-Tiki Star)


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Immunization History

• No allergies to food, medications, pollen noranimals

• Hasn’t had any other illnesses nor injuries

Past Illnesses

•

Hepatitis B – 1 dose at birth


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Family HistoryFamily Member Age Occupation Diseases

Father 28 Container van driver None

Mother 28 Housewife None

Siblings 6 None None

4 None None

•

No medical problems for blood-relatives such astuberculosis, diabetes, cancer, epilepsy, rheumaticfever, allergy, asthma, hypertension, heart disease,stroke, kidney disease, blood disorder nor mentaldisorder.


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Socioeconomic History

• Living conditions

– Currently lives in an apartment with one

bedroom, occupied by 5 other family members

• Economic circumstances

– Two members of the family, the patient’s father

and uncle have jobs and their incomes are the

family’s source of funds


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Environmental History

• Has exposure to cigarette smoke from her

father and uncle

• No other pollutants identified

• Garbage collected periodically however they

resort to burning of garbage materials when

there’s none, about once weekly


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PHYSICAL EXAMINATION


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General Survey

• Quality of cry: slightly weak cry (whimpering)

• Reaction to parent stimulation: Cries briefly thenstops

•

State of variation: if asleep and stimulated, thenwakes up quickly

• Color: Pink

• Hydration: Skin Normal and and eyes, mouth

moist; CRT


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Vital Signs

• T: 38.3 C, axillary

• HR: 120 bpm , regular

•

RR: 50 bpm, regular• Acute Ilness Observational Scale: 8


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Anthropometric Data

• Weight: 6.5 kg

• Length: 62 cm

•

Head circumference: 39cm• Chest circumference: 36cm

• Abdominal circumference: 37cm

• BMI: 15.61


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Skin

• (-) pallor, jaundice, flushing, cyanosis

• pinkish

• fair skin tone

• smooth, no breaks

• (+) erythematous papulovesicular rash (diaperarea)

• moist in skin folds

• normal skin turgor


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Head

• no trauma

• normocephalic

• Scalp: no infestations, clean

• Hair: fine, normal distribution

• (-) swelling, hematoma, abscess

• Symmetrical facial expression

• Fontanels: – AF: slightly depressed, pulsatile, open

– PF: closed


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Eyes

• Eyelids: symmetrical

• No periorbital edema

•

pinkish conjuctiva• anicteric scelra

• equal pupil size

•equal accomodation and convergence


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Ears

• normoset external pinnae

• no discharge

•

(-) tenderness• (+) gross hearing


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Nose

• symmetrical nasolabial folds

• midline septum

• pinkish mucosa

• no discharge

• both nostrils are patent


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Mouth and Pharynx

• midline tongue

• lips: pinkish, cutest

• gums pinkish

• no teeth

• uvula midline


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Neck

• midline

• (-) palpable thyroid, lymph nodes


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Chest and Lungs

• AP diameter = transverse diameter

• Movements with respiration: mostly

abdominal

• (-) chest retractions

• symmetrical chest expansion

•

vesicular breath sounds: all lung fields• (-) adventitious breath sounds


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Cardiovascular

• Inspection: No observed precordial bulging.

No visible pulsations in the chest

• Palpation: PMI measures approximate 2cm on

left 4th intercostals space MCL, no thrills.

• Percussion: Not done

• Auscultation: No abnormal murmurs or heart

sounds (S3 and S4) noted. No pericardial

friction rub


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Abdomen

• Inspection: Abdomen is globular and symmetric.No visible superficial veins, scars, or localized areaof bulging, masses and other lesions.

• Auscultation: With audible normoactive bowel

movement sounds (7/min) gurgling in quality. Nobruits auscultated.

• Palpation: Soft and non-tender abdomen. Nonoted involuntary rigidity or muscle guarding. Liver

edge is not palpable over the right costal margin.Non palpable spleen.

• Percussion: Not assessed


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Genitalia

• Grossly female

• Size, location of labia, clitorius, meatus and

vaginal opening are normal for age

• Tanner stage 1

• No discharge or pseudomenses


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Peripheral vascular & Extremities

• No tremors, no twitching, no involuntarymovements

• No clubbing, edema, swelling and deformities

noted• No tenderness noted

• Capillary refill < 2 seconds

• Pink nail beds

• Radial, and dorsalis pedis pulses 2+ for both leftand right extremities


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NEUROLOGICAL EXAM

C i l N


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Cranial NervesCRANIAL

NERVES

FINDINGS

I N/A

II N/A

III N/A

IV N/A

V N/A VI Eyes are symmetrical. Pupillary size equal, equally reactive to

light, direct and consensual pupillary reflex, accommodation and

converegence

VII N/A

VIII Gross hearing is intact

IX N/A

X N/A

XI N/A

XII Tongue is at the midline. No atrophy, grooving or fascuculations


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Neurological Exam

• Motor Testing

o Examination of the gait and posture, musclebulk, muscle tone and strength and

coordination is not applicable in theexamination of the patient

• Cerebellar Function (N/A)

• Sensory Testing (N/A)


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Reflexes

Reflexes Score

Deep Tendon Reflex

Patellar reflex 2+

Primitive reflexes Moro reflex

Rooting reflex

Grasp (Palmar and Plantar) reflex Babinski

Tonic neck reflex

+

+

+ +

+


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Reflexes

• Deep Tendon Reflex

– Patellar Reflex 2+

• Primitive Reflexes (all positive)

– Moro

– Rooting

– Palmar and Plantar Grasp

– Tonic Neck

– Babinski


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SALIENT FEATURES


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• < 2 months old

• Previously healthy

• Parental smoking

• History of mild upper respiratory infection manifested by colds with clearrhinorrhea.

• No fever

• Cough

• Signs of respiratory distress:

Dyspnea

Irritable Effortful breathing

Weak cry

Grunting

Alar flaring

Subcostal Retractions

• No tachypnea

• No crackles

• No wheezing

• No other systemic symptoms


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APPROACH TO DIAGNOSIS


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COUGH

w/ signs ofrespiratory

distress

No othersystemic

symptoms

Respiratory

system OtherSystemsAcute (3weeks)

Viral

PneumoniaAcute

Bronchiolitis

Bronchialasthma

ObstructiveSymptoms

RestrictiveSymptoms

i l i


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Viral PneumoniaRule in Rule Out


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Bronchial AsthmaRule in Rule Out

•

Epidemiology: Most common chronic diseaseof Childhood and 33% before 2 y.o.

• Parental smoking

• History of mild upper respiratory infection

manifested by colds with clear rhinorrhea

• No fever

•Cough

• Dyspnea

• Irritable

• Effortful breathing

• Weak cry

• Grunting

• Alar flaring• Subcostal Retractions

• No other systemic sxs

•

No family history of Asthma• No Intermittent dry coughing

• No expiratory wheezing

RULED OUT

A B hi li i


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Acute BronchiolitisRule in Rule Out

1 month old The infant first develops a mild upper

respiratory tract infection with clear

rhinorrhea

Temperature can range from subnormal to

markedly elevated Respiratory distress ensues, with paroxysmal

wheezy cough, dyspnea, and irritability.

The child does not usually have other

systemic complaints, such as diarrhea or

vomiting

Apnea may be more prominent than

wheezing early in the course of the disease,

particularly with very young infants (


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ACUTE BRONCHIOLITIS

Working Diagnosis


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DIAGNOSTIC WORK-UP


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Diagnostic Work-Up

• Diagnosis is basically made clinical and based

upon history and physical examination

(Kliegman et al., 2010).

• However, because concurrent bacterial

infection is highly unlikely, confirmation of

viral bronchiolitis may obviate the need for a

sepsis evaluation in a febrile infant (Kliegmanet al., 2010).


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CBC and Differentials

• To look for coexisting bacterial infection

• WBC and RBC differential counts usually normal (without the lymphopenia seen with other viral

illnesses) (Kliegman et al., 2010) – WBC count (8000-15000/ul) and may be left-shifted as

a result of stress (DeNicola, 2014)

– However, it is noted that mong infants with a febrile

illness, WBC values are highly variable. No WBC countthreshold has good discriminatory value for the presence of bacterial infection (DeNicola, 2014)


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Chest Radiography

• Useful in excluding unexpected congenital

anomalies or other conditions (e.g. lobar

pneumonia, congestive heart failure)

• AP and lateral views

• May reveal hyperinflated lungs with patchy

atelectasis

– difficult to distinguish from early bacterial

pneumonia (Nelson, 2003)


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Pulse Oximetry

• To determine severity of illness but does not ruleout other diagnoses (e.g. asthma, pneumonia)

• Transcutaneous oxygen saturation

–

good indicator of the severity of bronchiolitis – correlates best with tachypnea; however, correlates

poorly with wheezing and retractions (DeNicola, 2014)

• Persistent resting oxygen saturations


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Viral Testing

• To determine the viral pathogen to help guide

treatment

• Rapid immunofluorescence, ELISA, PCR

• Viral culture

– Standard for a definitve diagnosis

• RSV most commonly isolated organism (26-

95%) (DeNicola, 2014)


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MANAGEMENTManagement for patients with Acute

Bronchiolitis is directed toward symptomaticrelief and and maintenance of hydration and

oxygenation since there is no definitivetreatment for specific viruses.


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INITIAL MANAGEMENT

• Patient should be made as comfortable aspossible.

• Administer saline nose drops and perform

nasal and oral suctioning if needed.• Careful monitor for presence of apnea.

• Pay attention to temperature regulation in

small infants• Adequate hydration should be maintained and

careful fluid monitoring.


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CRITERIA FOR ADMISSION• Persistent resting oxygen saturation below 92% in room air before

beta-agonist trial• Markedly elevated respiratory rate (>70-80 breaths/min)

• Dyspnea and intercostal retractions, indicating respiratory distress

• Desaturation in 40% oxygen (3-4 L/min oxygen), cyanosis

• Chronic lung disease, especially if the patient is on supplemental

oxygen• Congenital heart disease, especially if associated with cyanosis or

pulmonary hypertension

• Prematurity

• Age younger than 3 months, when severe disease is most common

• Inability to maintain oral hydration in patients younger than 6months

• Difficulty in feeding as a consequence of respiratory distress

• Parent unable to care for child at home


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CRITERIA FOR ADMISSION IN ICU

• Worsening hypoxemia or hypercapnia

• Worsening respiratory distress

• Continuing requirement for more than 40%

oxygen• Apnea

• Acidosis

•

Extrapulmonary symptoms• Worsening mental status

• Unclear etiology of symptoms


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OXYGEN SUPPLEMENTATION

• Oxygen therapy should be started when:

– oxygen saturations are persistently below 92%

– significant respiratory distress.

• Maximum oxygenation via nasal prongs is 2.5

L/min


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MAINTENANCE OF HYDRATION

• Oral feeds can be continued if the child is able to

take greater than 50% of usual feeds without

significantly increased work of breathing.

• Feeding 2-3 times hourly with decreased volumemay be helpful.

• Encourage to continue breastfeeding

•Mothers should also maintain their oral fluids anddietary intake to prevent reduction in the supply

of breast milk.


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PHARMACOLOGIC THERAPY

• BRONCHODILATORS

– Produce modest short-term improvement in

clinical features

– Ipatropium bromide appears to be effective as anadjunct therapy.

– Not recommended routinely

–

Not recommended for infants


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• ANTIINFLAMMATORY AGENTS

– Corticosteroids whether parenteral, oral or

inhaled have been used for bronchiolitis despite

conflicting and often negative studies. – Corticosteroids are not recommended in

previously healthy infants with RSV (Kliegman,

2007)


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• ANTIVIRAL AND ANTIBIOTICS

– Ribavirin, an antiviral agent administered by aerosol, has

been used for infants with congenital heart disease or

chronic lung disease.

– There is no convincing evidence of a positive impact on

clinically important outcomes such as mortality and

duration of hospitalization.

– Antibiotics have no value unless there is secondary

bacterial pneumonia.


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Prognosis

Acute Bronchiolitis

• At highest risk for further respiratory

compromise in the first 48-72 hours after

onset of cough and dyspnea

• Child may be desperately ill with:

– Air hunger

– Apnea

– Respiratory acidosis


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Prognosis

• Case fatality:


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Prognosis

• After critical period of symptoms,

symptoms can persist

–

Median duration of symptoms inambulatory patients: ~12 days


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Complications

• Subsequent airway reactive disease

– Recurrent wheezing

– asthma


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Prevention

• Pooled hyperimmune RSV intravenousimmunoglobulin

• Palivizumab

– An intramuscular monoclonal antibody to the RSVF protein

– For infants


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References

• Kliegman, R. 2007. Nelson textbook of

pediatrics.18th ed. USA: Saunders Elsevier. p.

1474-1479.

• Mejias, A., M.W. Hall and O. Ramilo. 2013.Ummune monitoring of children with

respiratory syncytial virus infection. Retrieved

on 26 October, 2014 from www.patient.Co.uk/doctor/bronchiolitis-pro


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References

• Kliegman RM et al. 2010 Nelson Textbook of

Pediatrics. 19ed. Elsevier, Inc.

• DeNicola, LC. 2014. Bronchiolitis Workup.

Medscape. Retrieved on 26 Oct, 2014 athttp://emedicine.medscape.com/article/9619

63-workup#showall

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