SECTION 1

ACUTE BRONCHIOLITIS

IntroductionCommon disease of lower

respiratory tract in infantsCommon age group: 1-3

monthsCommon during winter

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

Non-viralMycoplasma

No bacterial etiology

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

Pathophysiology

Pathophysiology Bronchiolar obstructionMinor bronchial wall

thickeningResistance α

Air trapping & overinflation Atelectasis

1

radius4

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

Wheezy cough

Clinical featuresPhysical examinationsTachypnea doesn’t correlate

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

Bronchiolitis

Investigations Chest – X – Ray:Hyperinflated lungs with

patchy atelectasis

Flat diaphragm

Increased peri-hilar bronchovascular markings

Investigations WBC count: Normal

(without lymphopenia) Diagnosis:Healthy infant first t ime

wheeze during winter

Differential diagnosis

Bronchial asthma- family history atopy

CCF- suck rest suck cycleFB aspiration- sudden

onset, choking episodeBacterial pneumonia- sick

child

Course & PrognosisHighest risk (cough &

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

acidosisApneaSevere dehydration

Course & PrognosisRisk factors for severe

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

TreatmentHospitalize - hypoxia,

inability to take oral feedings, apnea, extreme tachypnea

Supportive therapy- IV fluids, humidified oxygen, careful monitoring

No sedation- clear upper airways

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

Prevention Meticulous hand washing

STRIDOR AND ALTB

Section 2

StridorHarsh, high-pitched

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

Causes Acute Onset

ALTB

Epiglottitis

Foreign body

Retropharyngeal abscess

Bacterial trachiitis

Peritonsillar abscess

ChronicVascular ring

Laryngomalacia

Vocal cord dysfunction

ALTB Causes- Viruses-

Parainfluenza virus 1,2,3Inflammation of Larynx,

trachea and bronchus

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

Croup

Investigations X ray- Steeple signCroup is a clinical

diagnosis and does not require a radiograph of the neck

Steeple sign

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

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

EpiglottitisBends

forwardTripod

positionDroolingToxic child

Epiglottitis

Thumb sign

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