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W E L C O M E A L L
ABDOMINAL PAIN IN CHILDREN
At the end of this session you will learn
• Anything in abdomen can cause pain• Huge overcrowded abdomen has many c/of AP• Most RAP in children are functional• Alarm signs are clues to severe disease• Abdo. migraine may mimic ac. abdomen• RAP with positive MT is suggestive of Abdo. TB• Infantile colic is self-limiting
• ENT infx. is an important c/of ac. AP in children
AP: abdominal pain. RAP: rec. abdominal pain
Introduction
• Almost all children express AP: 5-7% of all ED visits• Most are functional: no anatomic, metabolic,
inflammatory, neoplastic cause. Need no tests• Familial illnesses, environment, parental attitude are
important predisposing factors for AP• Chr. and RAP overlap, ~synonymous
• Never miss medical and/or surgical emergencies
Functional AP (FAP): Clues
• Otherwise healthy/thriving• Good appetite, no NVD• Short episodes, environmental triggers• Periumbilical• Normal PE• FH of RAP/migraine• No tests to DD. Alarm SS justify further inv.
PE: physical examination. DD: differential Dx or differentiate. SS: symptoms and signsInv: investigate
Nature of abdominal pain
• Persistent: aching, burning, pressing, pricking, stabbing
• Colicky/spasmodic: muscle spasm. (coming and going)
• Pain may be diffuse, localized, referred• Mostly are non-surgical. Bilious V may suggest
obstruction/malrotation• Referred Pain: pain felt at another site, not site of origin
(subphrenic ab.: shoulder pain). Why? Somatic and visceral afferents enter the cord closely as of embryonological origin
V: vomiting
Visceral AP: dull, poorly localized, crampy, burning, biting (mechanical stretching or chemical irritation)
Parietal pain: parietal peritoneum. Sharp, well-localized
Generalized pain (felt “everywhere“ but may yet have a local c/): peritonitis, SCD, DKA, adrenal crisis, ac. intermittent porphyria, AGE, bloating/gas, IBS, IBD, obstruction, mesen. Ischemia/LAP, pregnancy
Abdominal migraine: paroxysmal central AP with features of migraine and ANV or pallor as well as FH of M
SCD: sickle cell disease. DKA: diabetic ketoacidosis. AGE: ac. Gastroenteritis. IBS: irritable bowel
syn, IBD: inflam. Bowel d. LAP: lymphadenopathy
Referred pain/reflective p, is felt at a site other than
the site of origin
Onset• Ac./Sudden: perforation, mesentaric infarction, ruptured
AA aneurysm, DKA, Addison D, MIAc. progressive: appendicitis, AGE
• Recurrent/chronic
SiteMay not be specific. Changes in site may mark progression• Diaphragmatic/GB pain may feel at shoulder• Appendicitis: McBurney’s point• Cholecystitis: Murphy’s point• Renal pain: loin to groin• Perforated ulcer: severe diffuse (peritonitis)
Upper abdomen:AGE, PUD, MIEarly appendicitisPancreatitis
Lower abdomen:Non-specificColicEarly appendicitis
Pelvis:ConstipationUTI, UB retentionPelvic appendicitis
Right sideBiliary, hepatitisappendicitisenteritis/IBDovarian
Left sideSpleen/EBVConstipationNon-specificOvarian
Site
Aggravating and Relieving factors
• Peritonitis worsened by movement: lie still• Fatty foods worsen biliary colic, pancreatitis• Eating relieves DU; worsens GU, mesen. ischemia
• Defecation relives colitis pain• No change in renal colic, MI, appendicitis, hepatitis,• Menstruation worsens PID, endometriosis
DU: duodenal ulcer. GU: gastric u. MI: myocardial infarction. PID: pelvic inflam. Ds.
Causes of Upper AP• Hepatitis/Ca/cholangitis/cholecystitis/duodenitis/ CHPS:
RC. Gallstones: R• Dyspepsia/ gastritis/Food P/PUD/ GERD/hiatal H: C • Pancreatitis/intestinal O/injury/mesen. Ischemia/NHL: CRLB• Extra abdominal: ENT infx./pericarditis: C
MI/ pleurisy: CRLB, Pn.- RLB, Pneumothorax- RL, thoracic A. aneurysm- LC
• Infantile colic
right, left, both, center, pelvic: R, L, B, C, PCHPS: cong. Hypertrophic p. stenosis
Lower AP
• Appendicitis- RC, Cancer- RLCP, Crohn's D- LC• Diverticulitis/inguinal H- RLB• Endometriosis- CRLBP, intestinal O.- RLC• Injury- RLBCP, Kidney Infx.- RL, - stones- RLBP• Ovulation/PID- RLCP, ovarian cysts- RL, preg.- CP,
salpingitis/ectopic P- RL, seminal vesiculitis- RLBP• Dysmenorrhea-C, endometriosis-~• Constipation-LC, anal fissure, polyp- P
The above list is incomplete
Look for specific signs
• Murphy’s sign • “Sausage”, Dance’s sign: retraction of the RIF (intussusception)• Rebound tenderness at McBurney, Rovsing’s, psoas sign,
obturator sign• Cecal “squish”• Hernia’s torsion
Extra-abdominal c/of Acute AP
• ENT infx.• Lower lobe pn.• MI• Addison D• DKA• A. migraine
• Sickle CD• Porphyria• Lead P• NAI• HS Purpura
NAI: non-accidental injury
Pointers for Surgery
• Peritonitis: F, distended board like silent abdomen• Obstruction: V, constipation, distension, high pitched BS
• GI bleeding: hematemesis, melena• Appendicitis: RIF pain, LGF, tachycardia, ANV. Rare <2y age
Operate NOW
• Perforated viscus, appendicitis• Vascular compromise: malrotation, volvulus,
incarcerated H, torsed gonads, non-reduced intussusception, ischemic bowel obstruction
• Uncontrolled intra-abdominal hge., ectopic preg.
Operate SOON• Intestinal obstruction, non-perforated appendicitis• Refractory IBD, tumors
No Early Surgical Referral
• Gastroenteritis • Infantile colic• Poisoning• Constipation • PUD, gastritis• Hepatitis
• Pancreatitis, mumps• Worms • Cholecystitis/cholangitis• UTI, NS, Urinary calculus • Dysmenorrhea
DD
Age: consider FAP in ages 4-18y• Ac. cholecystitis: RUQ pain R scapula, Murphy’s• Ac. appendicitis: ANV, periumbilical, settles in RLQ
in 6-8hrs, F, localized peritonitis, mass• Pancreatitis: upper AP, ANV, back pain• IBD: bloody stools, F, wt. loss, arthritis, uveitis• Ac. diverticulitis: mostly sigmoid colon, SS of
inflammation or obstruction. CT useful
FAP: functional AP
• Bowel Obstruction: 70% in adults are post-op. adhesions, incarcerated hernias. Bilious and fecal V distal obstruction. AXR
• Perforated DU: usually duodenal bulb, sudden ac. pain, peritonitis. AXR
• AAA: ac. tearing AP, tender mass in 90%, hypotension, pulsatile mass in 75%. Alert surgeons/anesthetist/theater
AXR: abdominal xray. AAA abdominal aortic aneurysm
• Ac. mesen. ischemia: pain with eating, abdo. bruits., ac. periumbilical AP disproportionate to physical SS– consider in AF, acidosis may herald it– surgery if acute vascular occlusion noted
• Others: endometriosis, salpingitis, tubo-ovarian abscess, ovarian cysts/torsion, ectopic P
Rectal Polyp
Polyposis coli: polyps of various size along the entire colon
Peutz-Jeghers syn.: polyps in small bowel and oral pigmentation
Meckel's diverticulum
Investigations: Ac. AP
• Urine: glucose, protein, blood, ketone, CS• CBC, glucose, LFT, amylase, electrolytes• Sickling test for African child• AXR (erect and supine)• USG if needed
Infantile Colic
• 3 mo. colic. Cries >3h/d x >3d/w x >3w• Starts: at 2w in FT or later in preemie. Goes by 3-4mo.
Parenting may be v. stressful• No difference in sex, feeding nor in development• Exclude: otitis, UTI, GER; gut, CNS, heart, eye problem,
fracture, hernia, discomfort, insects
Causes• Not known. No single cause. Overfeeding, undiluted juices,
food allergies, aerophagy, separation stress can aggravate it. Others:– Intolerance of CM protein or lactose; GER– Air in tummy; gut muscles are often in spasm– Hypersensitivity to sound, light, etc.– Increased hormone levels
Rx
• Reassure. Burping. Keep upright after feeds. Change feed, hypoallergenic. Add lactase
• Mom to avoid caffeine, milk, certain vegetables and herbal• Change nipples of bottle • Swaddle your baby. Try massage• Put a warm water bottle on your baby's belly• Warm bath. Try an infant swing• Increase/decrease stimulation in the environmentMedications: No self-medication. Anti-reflux if GER. Anti-gas
drops. Diphenhydramine
Appendicitis
• Common. Progressive. Perforation rare on 1st d• Bacteria infect its wall. May be gangrenous, perforated• Commonest SS: AP, ANV, F, tenderness • Dx: clinical. TLC , DLC, urinalysis, AXR, USG, CT, laparoscopy• Complications: rupture, abscess, peritonitis. Variable
size, location, proximity of other organs may make it difficult Dx
• Rx: AB and surgery• DD: Meckel's D, PID, GB disease, perforation, diverticulitis,
kidney D, salphingitis, abdo. migraine
Pyloric Stenosis (CHPS)
Hyp
ertr
ophy
of p
ylor
us –
thic
keni
ng &
elo
ngati
on
Cause is unknown. Associations:– Abnormal muscle innervations– Erythromycin in infant, hypergastrinemia
• 3/1000LB: more in whites• M:F= 6:1. Age: 1 w–5 mo (3-6 w)
SS: AP. Nonbilious V on feeding (91% projectile) usually in the 2nd week of age; hungry after V, wt loss, progressive jaundice in 5%(Indirect HB from low glucuronyl transferase)
Examination
• Abdominal distension• Olive mass – RUQ, after feeding
Gastric peristalsis L to R after feeding
Tests
• Low chloride, raised bicarb., BUN and creatinine, ± hypokalemia, ± raised indirect bilirubin
• Plain AXR:• Ultrasound:• Upper Gut Imaging:
Incr
ease
d ga
stric
air
or fl
uid
sugg
estiv
e G
O o
bstr
uctio
n
USG: pylorus >15-19mm, thickness >3-4mm, diameter >10-14mm. Shoulder sign: indentation of pylorus into stomach
Upper Gut Imaging
• String sign: pyloric spasm
Treatment
• Resuscitation first: IVF, K+; correct alkalosis (apnea with GA)
• Pyloromyotomy• Endoscopically-guided balloon dilation if surgery is
CI or incomplete pyloromyotomy
Postoperative: feed within 12-24 h (4 h in 1 study)• Vomiting is Not a reason to delay feeding
– GER: 80% post-op– UGI if vomiting persists > 5days
Pyloromyotomy
Intussusception
Invagination of intestine into itselfCause: idiopathic (75% ileocolic; ileoileal)Hyperplasia of Peyer patches in terminal ileumStructural: lymphoma, Meckel DSystemic: cystic F, HSP, Crohn’sM:F=3:2. Age: 3-9 mo (80% <age 2)
Pathophysiology
• Proximal bowel telescopes into distal segment
• Compression of mesenteric BV & lymphatics leads to edema, ischemia, mucosal hge., perforation, and peritonitis
Intussusception: distal small gut obstruction
Ileocolic intussusception
Massive fresh PR bleeding from Meckel's D
CF
• Intermittent, severe cramps with loud cry in curled up position in a previously healthy child
• Vomiting• Currant-jelly stool• Lethargy • Appear normal between attack• Sausage like mass
Mixture of blood and mucus, foul smelling: currant jelly
Tests
• AXR: plain & contrast or air enema (Dx and Rx)• Electrolyte imbalance• CBC: leukocytosis• Ultrasound• CT scan: only if other tests are negative
Contrast: between intussusceptum and intussuscipiens gives coil-spring appearanceUse water-soluble agent prior to barium if high risk of perforation suspected
USG: can Dx ileoileal I. and identify the lead point of intussusception in 2/3rd cases in which underlying pathology exists
Treatment
Air/contrast reduction– Air is better than Ba: less perforation (<1%)– Not very successful if SS >24–48h or with obstruction– Success: 75-90% with ileocolic type
Surgery• Indications: persistent filling defects, failed nonoperative
reduction, prolonged intussusception• Manual reduction and end-to-end anastomosis
Recurrence:• 10%. Not necessarily an indication for surgery
Reduction
Malrotation & Volvulus
• The gut starts as a straight tube. Midgut (distal duodenum-midtransverse C) elongates and protrudes in U cord and lies totally outside
• It rotates around SMA. Duodenum re-enters and get fixed to posterior wall, colon is directed to LUQ
• Then cecum rotates counterclock and lies in RLQ. The colon and mesen. root is fixed to posterior wall
• Such attachments provide a broad base of support to the mesentery and the SMA and prevent twisting
• Completed in 1st TM
Normal development
Midgut volvulus
Cecal volvulus Sigmoid volvulus
band
Cork-screw pattern – barium flowing through restricted bowel lumen
Pathophysiology : bowel O: bowel wall dilation increased secretionsFig. 1: normal, F2 obstruction. Always check for air in rectum
Midgut volvulus with rapid distension
CF
• Bilious V• Rapid abdominal distension
INV:• UGI: duodenum not crossing the midline• Barium enema: malposition of cecum
Rx: surgery
RECURRENT AP/CAP
• Very common. • Criteria: 3 episodes of pain/3mo; severe to affect activities• 90% functional• RAP should not be used as a synonym for FAP*
RAP/CAP is complex, multifactorial Parental anxiety in 1sty of a child: more CAP <6y age; also if
parent(s) have GI problems orphysical illness• 25-50% continue it into adulthood; or have IBS and other
unexplained SS or depression
Chronic AP: Alarm SS
• Wt. loss/FTT; stunting• GI bleeds• Significant V, abdo. distension• Chr. D• Unexplained F• Persistent RUQ/RLQ pain, away from umbilicus• Family H/ of IBD
The History
• Age, duration, site, type, severity, timing• F, V (bile, blood, projectile, timing)• D, constipation, melena, flatus. Food allergy• Aggravating and relieving factors• Genitourinary complaints• Travel, diet, contact history• Medications • H/ of abuse (NAI)
The Teenage Female
• Menstrual h/: regularity, LMP, character, dysmenorrhea• Pelvic/bimanual exam with CS• Pregnancy test/urinalysis• USG• Laparoscopy
DD: ovulation, PID, ovarian cyst/torsion, endometriosis, ectopic P, UTI, PN
Physical Examination
Aim• To confirm suspicions• To localize diseased area• To exclude extra-abdominal causes
Ensure: warm hands, room. DistractionExam from least to most painful areaUnhurried, thorough exam. Plan for serial exams
contd.
Inspection: appearance, activity, diaphoresis, pallor, pigment, agitation, intensity of pain
Palpation: guarding, mass, tenderness, rebound, organomegaly, distention, bruise, scars, hernias. See vitals
Percussion: liver size, tympany Auscultation: BS, pitch, bruits
contd.
• Mild tenderness AGE• Still patient, tender, rigid peritonitis (shake bed, deep
breath)• Agony colic, bowel obstruction• Think of lower lobe pneumonia, MI• Old and very young may present very atypically• Elderly, diabetic, immunocompromised may present with
minimal SS
Pelvic, Genital, PR, hernia for each pt. with severe APcontd.
Bloody Stool
• Newborn: ingested maternal blood, VKD, formula intolerance, NEC, volvulus, Hirschsprung
• Infants: Anal Fissure, colitis, Meckel’s, milk allergy, polyps, HUS, IBD, Intussusception
• 2-6 y: colitis, polyps, AF, Meckel’s, IBD, HSP• Older: IBD, colitis, polyps, hemorrhoids
VKD
Bloody Vomit
• Newborn: ingested maternal blood, drug, gastritis, DIC
• Infants: ulcers, gastritis, esophagitis• 2-6 y: ulcers, gastritis, esophagitis, varices, FB• 6 y and older: ulcers, gastritis, esophagitis, varices
Upper GI Hge
• Eesophageal varices, Mallory Weiss, esophagitis
• PUD, Tumor, NSAIDs, aorto-enteric fistula
Presentation• Hematemesis, melena• Hypovolemia, shock, anemia• Recent AP, NSAIDs
Investigation: RAP
Extensive work-up usually negative. Tests is NOT
REQUIRED in children without alarm SS
• CBC and DC, electrolytes
• Urinalysis, CS, renal function
• X-rays: AXR, KUB, CXR. MT
• USG, laparoscopy, CT
• Stool: OBT, ME, CS. LFT, pancreatic tests
• Pregnancy test in all women of reproductive age
Imaging
• Erect AXR: obstruction: air/fluid levels, dilated loops, air in the rectum, fecalith, paucity of air in the right side
• USG for biliary or pelvic symptoms • CT Abdomen and pelvis: evaluates vasculature,
inflammation and solid organs
Use of Laparoscopy
• Diagnosis– non-sp. AP– chr. AP– female patients– undescended testes– Trauma– Tb
• Treatment– appendicitis– Meckel diverticulum– cholecystitis– ovarian
detorsion/excision– lysis of adhesions
Rx of Chr. AP/RAP
• Reassurance: if no alarm SS• Peppermint oil is effective in IBS• Pizotifen for A. migraine. H2B if dyspepsia• Cognitive BT is effective to reduce pain• Not enough evidence that analgesic, sedative, anticolic, etc. are effective; nor extra fibre, lactose free food or lactobacillus
Parental factors rather than psychology of child predict the persistence or recurrence of AP
Continuous attention/suggestion/proxy causes more persistence of pain Recovery is usual if parents accept the Dx
Don’t focus on complete cure; rather on return to normal function
ABDOMINAL MIGRAINE in children
• Variant of migraine; HA unusual. Common• In 2% children. Girls more. Age: 2-10y• Cause is not clear. May have neurologic and
endocrine factors and may be c/by alterations in levels of serotonin and histamine
• FH of M (60%)• Triggers: chocolate/nitrite-containing foods, stress,
and anxiety
SS• Adult migraine: HA, sometimes preceded by aura. NV,
photophobia. AM is rare in adults• AM: central AP and can be severe, often periumbilical;
crampy, ~NV. Pallor is common. ~HA. Relieved by sleep and can last 1 h-several days. Often precipitated by usual triggers of classic M
Dx• Difficult to diagnose, especially during the first episode. no
specific test. Dx by exclusion. Lab and imaging to rule out other conditions
• EEG to rule out a seizure disorder
Treatment
• Aims: relieve ac. attack and prevent recurrence• No ideal single drug. Drugs for adult M are used:• NSAIDs/acetaminophen• Sumatriptan in older children• Tricyclic AD and drugs that block serotonin, ergotamine
have been used in some• Valproic a.; pizotifen
• Long term low dose aspirin and beta-blocker to reduce frequency
• Cyproheptadine is effective in some• IVF if V is severe along with sedatives or antiemetic• Avoid triggers. Avoid food triggers. Stress
management and relaxation programs benefit some
Prognosis• Good; most children grow out• 70% develop M in adulthood
Air under diaphragm: perforated viscus, biliary fistula, cholangitis, gas producing MO, portal pyema, post surgical, abortion, peritoneal dialysis, trauma
Most likely
Large bowel obstr.Small bowel obstr.Generalized ileusLocalized ileusFree
intraperitoneal air
Most likely
Large bowel obstr.Small bowel obstr.Generalized ileusLocalized ileusNormal bowel gas
pattern
Most likely
Large bowel obstr.Small bowel obstr.Generalized ileusLocalized ileusNormal bowel gas
pattern
Most likely
Large bowel obstr.Small bowel obstr.Generalized ileusLocalized ileusNormal bowel gas
pattern
Most likely
Large bowel obstr.Small bowel obstr.Generalized ileusLocalized ileusNormal bowel gas
pattern
Pneumobilia after passage of a gallstone. Take a good look at the liver where the biliary tract is outlined by air
Fecal impaction: large stool ball in rectum with proximal dilation. Consider this in elderly with U retention
MCQ
• Most RAP are functional• Most ac. AP in children are functional• Pancreatitis as a c/of ac. AP in children needs a surgical
referral
• Fever is an alarm sign• Peritonitis does not need early surgical referral• Gas under the dome of diaphragm always indicates
perforation
WELCOME ALL
Bronchiole: A tiny continuation of the bronchi and connects to the alveoli. Resp. bronchioles the final branches
A clinical scenario
• Age: 5mo, formula fed, UR catarrh (rhinitis, -/+ cough, LGF x3d) then sudden fast br., tachycardia, chest indrawing, wheezing. Still playful, ~normal feeding
What is the Dx?
BRONCHIOLITIS
At the end of this session you will learn
• Bronchiolitis is a very common viral (RSV) ARI• Infants are most commonly affected• Self-limited• Prognosis is excellent• Needs only supportive Rx: mostly no ABT• It is uncommon in breastfed babies• Can cause hyperactive airways
INTRODUCTION
Bronchiolitis: inflammation of bronchioleswith excessive mucus and bronchospasm
• Common c/of hospitalization• May be associated with significant MM• Can cause Hyperactive/Reactive Airway:
– Bronchospasm from allergy/hypersensitivity– Mostly temporary– Not synonymous with BA; but asthma-like syn.– May later become BA (child is old enough for bronchial
challenge test)
MICROBIOLOGY
• Typically viral– RSV: 80%– Influenza, parainfluenza A B C– Rhinovirus– Metapneumovirus– Coronavirus (SARS. MERS)– Bocavirus
• Occasionally M pneumoniae
RSVUbiquitous• Seasonal
– Temperate SH: May-Sep, peak May-July– ,, Northern H: Nov.- April, peak Jan-Feb– Tropical: rainy season
• 90% by 2y age have exposure
METAPNEUMOVIRUS• Paramyxovirus; may co-infect with other viruses• May cause pneumonia
PARAINFLUENZA: Usually type 3SH: southern hemisphere
INFLUENZA VIRUS• Very similar to RSV or parainf. v. in CF• Similar in distribution to RSV
BOCAVIRUS: May cause pertussis-like illness
RHINOVIRUS• >100 serotypes! Mainly ‘common cold’• Affects LRT in children with chr. LD• Often co-infects with other viruses
CORONAVIRUS• 2nd commonest c/of common cold• Non-SARS types cause bronchiolitis• SARS, MERS
EPIDEMIOLOGY
• Typically 3-9 mo– 60% <6 mo; 80% <1y. Not beyond 5y
• 60% of all LRTI in infants. 3% hospitalized
Incidence: 31/1,000 infants
RSV in admitted pts.• 40% of all LRTI in 1st y of life• 20% of all LRTI in 5 y ..
PATHOGENESIS
• IP: 2-8 days• Inflammation, cell necrosis, ciliary damage• Edema, mucus, sloughed epithelium: block• Peribronchial lymphocytic infiltration (cuffing)
FACTORS FOR SEVERE B.
• Preterm, LBW, age: <6w• BA, Chr. LD or anatomical defects of airways• Cardiac disease, kidney disease• Immunodeficiency
• ENVIRONMENTAL : Smoking active/passive, overcrowding, child care centre, high altitude
CLASSICAL PRESENTATION
• Starts as URT catarrh: rhinitis, -/+ cough, LGF: 1-3d then: – fast br., tachycardia, chest indrawing, wheezing
• Mostly mild. Full recovery: 2-8w• No recurrence. If any, look for HD, BA, CF, etc.
PHYSICAL SIGNS
• Tachypnea: cut-offs– <60d 60 bpm (Preterm 70)– 2mo-12mo 50 ,,– 1y- 5y 40 ,,
• Vesicular br. with prolonged expiration, diffuse wheezes and crackles
• ~Dehydration• ~conjunctivitis or AOM• ~cyanosis or apnea in young infants
S/of SEVERE DISEASEIndication of admission: average stay: 3 d
• Toxic look, dehydrated, apneic spells• RR: >70. O2 <90% on room air, nasal flare (pneumonia)• Age <3 mo. Atelectasis. Parent unable to home care• Poor feeding• CO2 trapping• S/o HF• 2y infx.
Apnea in bronchiolitis
• 20% of admitted RSV B: < 2-3 mo, prematurity• May be the presenting symptom• Recurrence rate 50% • Mortality < 2%
Dehydration in ARI
• Fever• Fast br.• Poor intake• Vomiting• Runny nose• Parenteral diarrhea
DIAGNOSIS: Clinical
• Based on: h/o and PE
• Supported by CXR
• hyperinflation, flat diaphragm, air bronchograms,
peribronchial cuffing, patchy infiltrates, atelectasis
Air trapping. Peribronchial cuffing due to wall thickening. Minimal focal atelectasis. Tubular heart. Flat low-set D
Peribronchial cuffing
DX: VIRAL ISOLATION
• Generally not warranted. It rarely affects Rx/outcomes – it may decrease AB use; may stop spread– may help guide antiviral Rx
• Nasal aspirate: Ag detection; EM; FAB tests; culture and PCR
OTHER TESTSMostly in complications
• CBC: 2y infx.• CRP: …• ABG to evaluate respiratory failure• CXR for pneumonia, heart disease
DD
• BA• Bronchitis/pneumonia• Chr. lung D• FB, GERD or aspiration• Cong. HD or HF• Vascular rings, bronchomalacia, complete tracheal rings or
other anamolies
COURSEDepends on co-morbidities. Usually self-limited
– wheezing may continue >1w– Anorexia and disturbed sleep may persist for 2-4w
TREATMENT: SUPPORTIVE CARE
• Clean airway with saline, correct dehydration• Antipyretics• Humidified O2. Mechanical ventilation for pCO2 > 55 or
apnea• Monitor:
– apnea, hypoxia– hydration, respiratory failure, HF
CHEST PHYSIOTHERAPY• Not recommended: no cl. improvement, nor reduces O2
need or shorten hospital stay• May increase distress and irritability
FLUID ADMINISTRATIONIVF in dehydrationMonitor for fluid overload as SIADH may occur
BRONCHODILATORS: Not recommendedConsider in severe wheezingAlbuterol/racemic epinephrine may work; but SE common: tachycardia, hypoxemia, tremor, constipation, insomnia, etc
Anticholinergics: No benefit
CORTICOSTERIODSNot recommended• May help in chr. LD or recurrent wheezing• Prednisone, dexamethasone• Inhaler: not helpful
RIBAVIRIN• Not routinely recommended• Very costly. May be useful in severe RSV• Must be used earlyANTIBIOTICS: No routine ABT. Used in 2y bacterial infx.
(positive culture, AOM, Consolidation on CXR)
NONSTANDARD THERAPIES
• Heliox– helium and O2 decreases breathing work– only small benefit in limited patients
• RSV-IG or Palivizumab– no improvement in routine cases
• Surfactant– may decrease duration of mechanical ventilation or ICU
stay
DISCHARGE CRITERIA
• Normal RR• Adequate feeding• No supplemental O2• Caretaker educated and confident; capable of bulb suctioning
PROGNOSIS: Excellent • MR <1% in admitted children• 80% deaths in infants
COMPLICATIONS
• Highest in high-risks• Apnea: in young infants• Respiratory failure: 15%• 2y bacterial infx. : 1%• Collapse, consolidation• Otitis media
PREVENTION
• Hand washing; avoid viral contact, smoking• New vaccine under trials• Hyperimmune Ig• MAB: palivizumab
– 55% less admission for preterm/chr. LD and 45% for cong. HD. Given monthly through RSV season
• Influenza vaccine
BRONCHIOLITIS AND B.A.
• RSV is a risk for recurrent wheeze (40%) and reduced FEV1 up to age 11y
• Association of RSV with later BA– may be a predisposition factor
Bronchiolitis obliterans (BO)• Or obliterative/constrictive B usually adenovirus.
Rare but fatal (irreversible): fibrosis +/or inflammation: block
B obliterans organizing pn. (BOOP) or cryptogenic organizing pn. (COP)
• Non-infx.; often in Rh A, or with amiodarone• CF and CXR show pn. But no response to ABT
Some interesting CX-Rays
CDH: Mainly the L side. Asymmetry of a hemidiaphragm or changing diaphragmatic levels. Gas-filled organs or a NGT within the chest confirm DX. confused in diaphragmatic paralysis or after lung reduction
surgery
CDH: Morgagni defect
Pneumoperitoneum: mostly perforation. Erect XR: air crescent under D. Sometimes, a double-wall, or Rigler's, sign can be seen which refers to internal and external air outlining the
intestinal wall
A tension PT: air under pressure: one-way valve. tracheal shift, hyperresonance and no BS, distended neck veins, hypoxia. affected lung collapses; widened IC spaces
Pneumomediastinum. Most commonly follows injury to esophagus/adjacent alveoli. CXR: free air may outline anatomic structures. Common findings are a thin line of radiolucency that outlines the cardiac outline, vertically oriented streaks of air in the mediastinum, a double bronchial wall sign, or lucency
around the right pulmonary artery, the "ring around the artery" sign. Air is most easily detected retrosternally on lateral CXR. Air is fixed in a pneumomediastinum and does not rise to the highest point
Airway FB, most often in children; the commonest site is R main B due to its being posterior, straighter, and wider. Indirect s/of
ingestion include focal overinflation with partial obstruction or collapse in complete obstruction. See a radiopaque object lodged in the R main
bronchus of a child
Aspiration pn.: aspirated flora or gastric contents. A. pneumonitis: from chemical insult. CXR: bilateral opacities in the middle or lower zones. Acute: infiltrates or lobar consolidation. Chr.: solidified mass
Rt. middle lobe collapse with obliteration of R heart border
A hydropneumothorax: esophageal rupture, trauma, gas-forming MO, bronchopleural fistula, surgery. See horizontal AF level
MCQs
• RSV is the commonest c/of bronchiolitis• ABT is usually required in B• Most B are later associated with BA• In EBF babies B is rare• Anticholingergic nebulization is beneficial in B• B is usually a killer D• SARS/MERS is caused by RSV• Antiviral Rx is beneficial in all B cases
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