Pulmonology Conference

PULMONOLOGY CONFERENCEGuanzon, Guerrero, Guerzon,Guevarra, Guinto, Gutierrez

General Data

LS 1 month old / Male Lives in Malabon City Roman Catholic Single Informants: mother and grandmother Good reliability

Chief Complaint:Difficulty of Breathing

7 days PTA (+) productive cough(-) fever, colds, vomiting, diarrhea, anorexiaNo consult was done. No medication was given.

6 days PTA(+) productive cough(-) fever, coldsConsult at a Pediatric clinic Medication:

Ambroxol, 0.25ml TID taken for 2 daysNo relief of symptoms

4 days PTA (+) difficulty of breathing, (+) fever (38.5 ⁰C) (+) productive cough(-) coldsConsult at a public hospital Medication

Salbutamol nebulization TID for 5days0.65% NaCl nasal solution with suctioning

Cefixime (unrecalled dose; #/day?; for how long?)Compliant relief of difficulty of breathing & lysis of fever

1 day PTA (+) recurrence of difficulty of breathing(+) productive cough(-) fever Salbutamol nebulization (how many times?)Relief?

10 hours PTA (+) recurrence of difficulty of breathing(+) productive cough(-) feverConsult at a pediatric clinic with an assessment of bronchial asthma and was advised admission.

ADMISSION

Review of Systems General: (-) weight change, (-) loss of appetite Cutaneous: (-) rash Heent: (-) excessive lacrimation, (-) epistaxis,

(-)excessive salivation, (-) nasal structures, Cardiovascular: (-)cyanosis, (-) fainting spells Respiratory: (-) cough, Gastrointestinal: (-) nausea, vomiting, (-)constipation,

(-)abdominal pain Genito-urinary: (-) frequency,(-)hematuria Nervous/Behaviour: (-) convulsions, stiffness Musculoskeletal: (-) joint swelling, (-) limitation of

motion, (-)limping Hematopoietic: (-)pallor, (-) abnormal bleeding, (-) easy

bruisability

Gestational History The patient was born term to a 20

year old primigravid. Mother had regular prenatal checkups. She denied smoking, drinking of alcoholic beverages, and use of illegal drugs during the pregnancy. Mother calimed non-exposure to chemicals, radiation, and viral exanthems. No complications noted during pregnancy.

Birth History

The patient was born term via CS, singleton, with no complications during and after delivery.

Neonatal History

The patient had spontaneous respiration, no pallor, no cyanosis, no jaundice and good cry. There was no note of gross congenital anomaly. The primary caregiver is the mother.

Feeding History

The patient was breastfeeding for 3 days. From 4th day the patient started formula feeding,Bona (2 oz of water and 1 scoop) for one month and shifted to Nan (2-4 ounces/feeding) since Jan. 17, 2010. Patient is currently on Nan (2-4oz/feeding).

Developmental Milestones

Can raise head slightly Hands fisted Eyes follow objects midline Has throaty, gurgling sound Regards face => at par with age

Past Medical History

No previous admission (-) allergy, (-) DM, (-) HPN, (-) cardiac/

renal disease (-) chickenpox, (-) measles, (-) mumps,

No previous surgery and transfusion

Immunization History

(+) BCG 1 (+) Hepa B 1

Family History

(+) HPN – maternal grandmother (+) allergies – father(to seafood) (-) Asthma (-) PTB, (-) DM (-) Cancer

Family ProfileName Age Relation Educational

AttainmentOccupation Health

Florante 32 Father High school copier healthy

Krystel 20 Mother High school House wife Healthy

Maja 66 Great grandMother

High school cook Healthy

Tirso 47 Grandfather

High school None Healthy

Anna 44 Grandmother

High school cook Healthy

Rufino 50 Grandfather

High school carpenter Healthy

46 Grandmother

college Elementary school teacher

(+)HTN

Albert 36 Grandfather

High school janitor Healthy

Alfie 27 Grand father

High school Tricycle driver Healthy

Shane 22 Uncle High school None Healthy

Chairmaine 18 Aunt High school None Healthy

John 17 Uncle High school Student healthy

Jennylyn 17 Aunt High school Student Healthy

Ann 11 Aunt High school g1 Student Healthy

Jed 11 Uncle Grade 5 Student Healthy

Sha-sha 6 Uncle kindergarten student Healthy

Socioeconomic & Environmental History

The patient lives with her mother, maternal grandmother and aunts and uncles in the maternal grandmother’s house, cemented, well-lit, well ventilated. The patient’s room is not-airconditioned. Water for consumption was district water supply. Garbage was collected daily. Patient has no exposure to cigarette smoke. No pets in the house. No factories nearby.

Physical Examination

Awake, alert, in respiratory distress, well-nourished, well-hydrated

VS: HR 124 bpm regular, RR 55/min, T 36.5 C, Wt: 4.38 kg Z(0)Ht 58 cm Z( below +2), WFH: Z(-2)

Warm and moist skin, no active dermatosis No head deformities, anterior and posterior fontanels not

depressed or bulging Pink palpebral conjunctivae, anicteric sclerae, eyeballs not

sunken Non-hyperemic EAC, TM intact, AU Nasal septum midline, (+) nasal discharge, turbinates not

congested Moist buccal mucosa, tonsils not enlarged, non-hyperemic

PPW

Physical Examination

Supple neck, (-) palpable cervical lymph nodes

Symmetrical chest expansion, (+) subcostal retraction, (+) crackles on both lung fields

Adynamic precordium, AB at 4th LICS MCL, (-) murmur,

Globular abdomen, NABS, no organomegaly, no mass

Full and equal pulses on all extremities, (-) cyanosis

Neurologic Examination

Awake, alert, responds to stimuli Pupillary reflex 1-2mm ERTL, no

facial asymmentry(+) corneal reflex (-) Tremor, abnormal limb movement Good muscle tone, bulk, no flaccidity

rigidity, spasticity (-) Meningeal signs

Salient Features

Pertinent Positives Difficulty of

breathing 1-day high-grade

fever FH of atopy Productive cough Nasal discharge Tachypnea Subcostal

retractions Crackles

Pertinent Negatives (-) FH of asthma (-) Cyanosis

DIFFERENTIAL DIAGNOSISFever, productive cough, retractions, crackles on both lung fields

Infectious Pneumonia Upper Respiratory Tract Infection Lower Respiratory Tract Infection

Non infectious Bronchial Asthma

Bronchial asthma

Reversible obstructive lung disease Cough, dyspnea, recurrent wheeze

worsening at night Mild, moderate or severe Relieved by inhaled B2 agonist

Mild Moderate SevereExertion (e.g. walking)

Talking, feeding At rest

May be agitated Usually agitated Usually agitatedUsually no retractions

With retractions & use of accessory muscles

With retractions & use of accessory muscles

Moderate end-expiratory wheeze

Loud wheeze Loud wheeze

Slight tachypnea and tachycardia

Tachypnea, tachycardia

Tachypnea, tachycardia

Absent pulsus paradoxus

Present pulsus paradoxus

Present pulsus paradoxus

URTI

Croup Etiologic agent: viral (Parainfluenza) Rhinorrhea, pharyngitis, mild cough, low

grade fever for 1-3 days before signs & symptoms of upper airway obstruction becomes evident

Barking cough, hoarseness, inspiratory stridor, tachypnea, retractions

Improves with epinephrine & steroids

Tracheitis Caused by Staphylococcus aureus &

Haemophilus influenza Gradual progression of respiratory

distress over 2-3 days accompanied by high fever

Subglottic narrowing Unresponsive to racemic epinephrine Treated with antibiotics

LRTI

Acute bronchiolitis Results from inflammatory obstruction of

the small airways Caused by RSV, parainfluenza, adenovirus Mild URTI, decreased appetite, fever,

paroxysmal wheezy cough, dyspnea, irritability

Tachypnea, nasal flaring, retractions, fine crackles, prolonged expiratory phase

Hyperinflated lungs with patchy atelectasis

Pulmonary TuberculosisExposure S/Sx CXR PPD Labs

PTb exposure + - - - -PTb infection +/- - + - -PTb disease + + + + +Inactive PTb +/- - + + -

Signs & Symptoms :• Cough of 2 weeks or more• Failure to return to normal health after an infection• Painless cervical lymphadenopathy• Weight loss or poor weight gain• Failure to respond to appropriate antibiotic therapy

Pneumonia

Common causes: H. influenzae, S. pneumoniae

Pneumonia Fast breathing, no chest indrawing

Severe Pneumonia Fast breathing, chest indrawing No central cyanosis

Very Severe Pneumonia Central cyanosis, inability to feed or drink,

stridor, convulsions, lethargic, severe undernutrition

Mechanism used in the diagnosis

Impression on Admission

t/c Pneumonia

Pneumonia

Pneumonia is a severe form of acute lower respiratory infection that specifically affects the lungs.

Two tell-tale symptoms of pneumonia: fast breathing difficulty of breathing

WHO & UNICEF: Pneumonia – the forgotten killer of children; 2006

Pneumonia

Characterized by inflammation of the alveoli and terminal airspaces in response to invasion by an infectious agent introduced into the lungs through hematogenous spread or inhalation.

The inflammatory cascade triggers the leakage of plasma and the loss of surfactant, resulting in air loss and consolidation. This is in contrast to pneumonitis, which is caused by noninfectious agents such as radiation or chemicals.

Pneumonia: eMedicine 2009

Increased Risk for Pneumonia Intubation, tracheostomy, impaired cough

reflex, and aspiration: provide infectious organisms with easier access to

the alveoli and terminal airspaces. Ciliary dyskinesia, bronchial obstruction, viral

infection, cigarette smoke, and certain chemical agents: These conditions create disruption in the

mucociliary blanket. Anatomic abnormalities (eg, sequestrations),

gastric fluid aspiration or other causes of noninfectious inflammation, altered pulmonary blood flow, and pulmonary edema: These conditions increase the predisposition for

pneumonia. Immunodeficiency and immunosuppression:

These conditions increase predisposition for pneumonia.


Infections Viral infections

Accumulation of mononuclear cells in the submucosa and perivascular space partial obstruction of the airway

wheezing and crackles. Alveolar type II cells lose their structural integrity and

surfactant production is diminished, a hyaline membrane forms, and pulmonary edema develops

Fungal infections Unusual and are typically found in patients with

inadequate immune function Diffuse infiltrate of organisms or focal areas of fungal

growth. Appear ill and may have more subtle physical findings


Infections Bacterial infections

The alveoli fill with proteinaceous fluid, which triggers a brisk influx of RBCs and polymorphonuclear cells (red hepatization) followed by the deposition of fibrin and the degradation of inflammatory cells (gray hepatization).

Resolution: intra-alveolar debris is ingested and removed by the alveolar macrophages consolidation decreased air entry and dullness to percussion

Inflammation in the small airways leads to crackles. Wheezing is less common than in viral infections.

The inflammation and pulmonary edema that result from these infections cause the lungs to become stiff and less distensible, thereby decreasing tidal volume. The patient must increase his or her respiratory rate to maintain adequate ventilation.

Poorly ventilated areas of the lung may remain well perfused, resulting in ventilation/perfusion (V/Q) mismatch and hypoxemia. Tachypnea and hypoxia are common.Pneumonia: eMedicine 2009

Canadian Medical Assoc J: A practical guide for the diagnosis and treatment of pediatric pneumonia;

1997

Academy of American Family Physicians: CAP in Infants & Children; 2004

Pneumonia Diagnosis

Chest X-rays and laboratory tests are used to confirm the presence of pneumonia, including the extent and location of the infection and its cause

Clinical symptoms Children and infants are presumed to

have pneumonia if they exhibit a cough and fast or difficult breathing.


Pneumonia Transmission

Aspiration Pathogens already present in a child’s

nose or throat and are then inhaled into the lungs, causing infection.

Contaminated air droplets Blood-borne infections Neonates - birth canal or from

contaminated substances contacted during delivery


Risk Factors

Undernourished children Not exclusively breastfed Inadequate zinc intake, are at higher risk of developing pneumonia Other illnesses, AIDS or measles, Living in crowded homes Exposure to parental smoking or

indoor air pollutionWHO & UNICEF:

Pneumonia – the forgotten killer of children; 2006


In developing countries acute respiratory infections cause up to 5 million deaths annually among children less than 5 years old.

Several risk factors increase the incidence or severity of pneumonia in children: prematurity, malnutrition, low socioeconomic status, passive exposure to smoke and attendance at day-care centres.10 Underlying disease, especially that affecting the cardiopulmonary, immune or nervous systems, also increases the risk of severe pneumonia


1997

Mechanism of Symptoms

In order to identify very sick children with cough or difficult breathing one checks two clinical signs: fast breathing and chest indrawing. When children develop pneumonia, their lungs become stiff. One of the body’s responses to stiff lungs and hypoxia is fast breathing. When the pneumonia becomes more severe, the lungs become even stiffer. Chest indrawing may develop. Its presence is a sign of severe pneumonia.

Clinical Assessment Pneumonia can be defined clinically as the

presence of lower respiratory tract dysfunction in association with radiographic opacity.

WHO has promoted an algorithm to assess children who present with cough and fever. Tachypnea, considers an increased respiratory

rate >50 breaths/min in infants >40 breaths/min in children >11 months

Suprasternal, subcostal or intercostal retractions indicates greater severity.


1997


Radiographic confirmation is considered the gold standard.

However, no finding in itself can be used to diagnose or rule out pneumonia. The absence of the symptom cluster of respiratory distress, tachypnea, crackles and decreased breath sounds accurately (100% specificity) excludes the presence of pneumonia (level II evidence).

Assessment of oxygenation gives a good indication of the severity of disease.

Oximetry should be considered in the assessment of a child with suspected pneumonia and in all children admitted to hospital with pneumonia, because the results correlate well with clinical outcome and length of hospital stay (level II evidence).


1997

Two classic presentations have been described for pneumonia: Typical pneumonia: fever, chills, pleuritic chest

pain and a productive cough. Atypical pneumonia: gradual onset over several

days to weeks, dominated by symptoms of headache and malaise, nonproductive cough and low-grade fever.

Unfortunately, the overlap of microbial agents responsible for these presentations thwarts identification of the causal pathogen on the basis of clinical presentation.


1997

The best predictor of the cause of pediatric pneumonia is age. During the first 2 years of a child’s life viruses are most frequently implicated. As age increases, and the incidence of pneumonia decreases, bacterial pathogens, including S. pneumoniae and Mycoplasma pneumoniae, become more prevalent.


1997

Radiographic Findings

A confirmatory chest radiograph is necessary to diagnose pneumonia. Bronchiolitis and asthma may cause hyperinflation and atelectasis and must be distinguished from pneumonia.

Two main patterns of pneumonia are recognized: interstitial and alveolar. However, these patterns cannot be used to identify the cause. Peribronchial thickening, diffuse interstitial infiltrates and hyperinflation tend to be seen with viral infections (level III evidence).

Canadian Medical Assoc J: A practical guide for the diagnosis and treatment of pediatric pneumonia; 1997

Radiologic Findings

Bacterial - Lobar infiltrates, pneumatoceles, abscesses Alveolar infiltrates, however, are also seen in bacterial as

well as viral disease and in Mycoplasma pneumonia. Pneumococcal - Circular infiltrates in the early stages M. pneumoniae infection - Diffuse infiltration out of

proportion with the clinical findings, lobar consolidation, plate-like atelectasis, nodular infiltration and hilar adenopathy

Chlamydial pneumonia may be indistinguishable from mycoplasmal pneumonia.

P. carinii pneumonia - reticulonodular infiltrate that progresses to alveolar infiltrates

Tuberculosis - Hilar adenopathy especially if the patient has epidemiologic risk factors

Canadian Medical Assoc J: A practical guide for the diagnosis and treatment of pediatric pneumonia; 1997


1997

Indications for Hospital Admission Age less than 6 months Toxic appearance Severe respiratory distress Oxygen requirement Dehydration Vomiting No response to appropriate oral

antimicrobial therapy Immunocompromised host Noncompliant parentsCanadian Medical Assoc J: A practical guide for the

diagnosis and treatment of pediatric pneumonia; 1997

Cough or Difficult Breathing

•Any general danger sign or•Chest indrawing or•Stridor in a calm child

SEVERE PNEUMONIA OR VERY SEVERE DISEASE

Give first dose of an appropriate antibioticRefer URGENTLY to hospital

•Fast breathing PNEUMONIA

Give an appropriate oral antibiotic for 5 daysSoothe the throat and relieve the cough with a safe remedyAdvise mother when to return immediatelyFollow-up in 2 days

No signs of pneumonia or very severe disease

NO PNEUMONIA: COUGH OR COLD

If coughing > 30 days, refer for assessmentSoothe the throat and relieve the cough with a safe remedyAdvise mother when to return immediatelyFollow-up in 5 days if not improving

SIGNS CLASSIFY AS IDENTIFY TREATMENT

Management

Prompt treatment of pneumonia with a full course of appropriate antibiotics is lifesaving.

Cotrimoxazole and amoxicillin are effective drugs against bacterial pathogens and are often used to treat children with pneumonia in developing countries. Infants under two months with signs of pneumonia/sepsis are at risk of suffering severe illness and death more quickly than older children, and should be immediately referred to a hospital or clinic for treatment


In general, oral antimicrobial therapy will provide adequate coverage for most mild to moderate forms of pediatric pneumonia. Parenteral therapy is typically reserved for neonates and patients with pneumonia severe enough to warrant admission to hospital.


1997


1997



Complications

Pleural effusion Spontaneous pneumothorax Empyema Abscess

Prevention

Immunization Adequate nutrition Exclusive breast feeding Zinc Reduce exposure to pollution


COURSE IN THE WARDS 1ST HD

Breastfeeding 15-30 mins every 2-3 hours; hold feeding if MV > or = 50

VS q2h & WOF: progression of respiratory distress D5 0.3% NaCl 500ml to run at 17-18 gtts/hr CBC with platelet & CXR (PAL) requested Meds:

Salbutamol neb, 1 neb q4h Hydrocortisone 18mg/SIVP now then q6h Cefuroxime 150mg/SIV infusion q12h 0.65% NaCl solution 3-4 gtts/nostril q6h then suction

COURSE IN THE WARDS

2ND HD Fever at 38.5 C Paracetamol 100mg/ml,

0.5ml q4h for T ≥ 38.5 C Fed with 1 oz milk formula q3h with

strict aspiration precaution D5 IMB 500ml to run at 17-18 ml/hr Salbutamol neb Salbutamol puff, 2

puffs q2h

COURSE IN THE WARDS

3RD HD Feeding as tolerated with strict aspiration

precaution D5 IMB 500ml to run at 13-14 ml/hr

4TH HD IVF to consume Continue IV Cefuroxime to complete 7

days Hydrocortisone Prednisone 10mg/5ml,

1.5 mL BID

Prognosis

Overall, the prognosis is good. Long-term alteration of pulmonary function is rare, even in children with pneumonia that has been complicated by empyema or lung abscess. Significant sequelae occur with adenoviral disease, including bronchiolitis obliterans. Death almost exclusively occurs in children with underlying conditions, such as chronic lung disease of prematurity, congenital heart disease, and immunosuppression. Pneumonia: eMedicine 2009

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