IAP RTI GEM

RTI – GEMRESPIRATORY TRACT INFECTIONS

– GROUP EDUCATION MODULE

Based on IAP CONSENSUS PROTOCOL FOR THE MANAGEMENT OF

RESPIRATORY TRACT INFECTIONS IN CHILDREN

Indian Academy of PediatricsPresidential Action Plan 2006

Respiratory Tract Infection Group Education Module- IAP

2

The process A group of conveners

and a mix of “experts” Sharing of

responsibility Wider representation

Review of literature on identified topics

Draft guidelines- meeting and discussions

RTI Facts – Booklet in ACT and FACT format

Group Education Meetings - RTI-GEMs


3

NATIONAL TASK FORCE for

RATIONAL ANTIBIOTIC THERAPY IN CHILDHOOD RESPIRATORY TRACT

INFECTIONS LED BY

NITIN SHAH (Chairperson) ROHIT AGARWAL (Convenor) VARINDER SINGH (Convenor) VIJAY YEWALE (Co-convenor) DEEPAK UGRA (Co-ordinator)

Members: (alphabetic order)

A Balachandran Mahesh Babu J Chinappa Krishan Chugh Bela Doctor S K Kabra

Indu Khosla Raju P Khubchandani

G Ghosh G R Sethi Rasik Shah

Meenu Singh Tanu Singhal

Advisers : YK Amdekar Raju Shah Tapan GhoshNTFRTI


4

Road Map Today

Basic understanding of the issue Starting with a syndromic approach

Child with a Fever, Cough, with or without Nasal/ Ear discharge

Child with Fever, Cough and Noisy breathing

Child with Fever, Cough, and Rapid & Difficult Breathing

Understanding RTI and rational

therapy


6

Why infections of Respiratory Tract?

About 3 million children die every year before they reach the age of 5 due to RTIs.

Of these, 1.9 million deaths occur in India.


7

What is rational antibiotic treatment?

Antibiotic prescription should ideally comprise of the following phases:

Perception of need - is an antibiotic necessary?

Choice of antibiotic – which is the most appropriate antibiotic?

Choice of regimen : What dose, route, frequency and duration are needed?

Monitoring efficacy : is the antibiotic effective?


8

What is the current practice? Five commonest reasons for antimicrobial drug

use among children with respiratory conditions: nonspecific upper respiratory tract infections, pharyngitis, otitis media, Sinusitis, and bronchitis

Most of these antimicrobials are often

unwarranted.


9

The first error Erroneous trust in their ability to treat all

infections (read fever) with antibiotic prescription. Many fevers are not due to infections Majority of infections seen in general practice

are of viral origin. Antibiotics often prescribed in the belief

that this will prevent secondary bacterial infections No evidence except where chemoprophylaxis

is advocated.


10

Errors galore Using the “best” cover with the latest, potent,

broad spectrum antibiotic. But it may not be the best and also not the safest too.

Injectables are used often than needed The duration of use is often not regulated. Often upgrade or change the antibiotics for a

patient who continues to have fever despite antibiotic use. Causes are many like incorrect diagnosis, incorrect

dose and/or route of administration or incorrect choice of drug, phlebitis, and not always due to antibiotic resistance.


11

Does it matter?

Drug Resistance is a function of exposure to drug

It is Genetic in origin Prevent Access to Site

Decrease Influx Increase Efflux

Inactivate Drug Change Site of Action

http://www.sciam.com/1998/0398issue/0398levybox2.html


12

Perhaps it matters more than we think it does

Versatile Genetic Engineers Equilitarian and Social Horizontal Transmission of

Resistance Genes among Species

http://www.sciam.com/1998/0398issue/0398levybox3.html Gene Transfer in the Environment. Levy & Miller, 1989

Child with Fever, Cough and Nasal or

Ear discharge

Pharyngotonsillitis Sinusitis Otitis Media

Watch this sign- The ball is in your court!


14

Supriyo falls ill

Supriyo, 1 yr male, Brought with history of acute

onset cough with rhinorrhoea.

What more would you like to know? What would you expect on

examination?

The ball is in your court!


15

acute onset, red eyes, rhinorrhea, diarrhea, No exanthema, hoarseness, cough +++ Similar cases in family Throat mild congestion


16

Clinically diagnosed : Seasonal viral pharyngotonsillitis

CBC / Throat Culture : not needed.

How will you Manage? General & Symptomatic Therapy Antibiotics : Not needed.


17

Therapy Rest, oral fluids and salt water gargling- mainly

supportive. Avoidance of irritants (e.g. smoke) Analgesics and antipyretics - Paracetamol DOC Normal saline nasal drops may help, particularly in <2yrs,

other nasal decongestants sparingly for short term First generation antihistamines may relieve rhinorrhea by

25 – 30%. Cough suppressants? Brandy/ soup/ other special Diet / Zinc/ Herbal products:

No confirmed role.

Takes 5-7 days to resolve, so do explain


18

6 year old Arjun was brought to your clinic with 2 day history of high spiking fever and mild cough

What more will you ask?

Case History



19

Acute onset, Has no red eyes, or rhinorrhea or diarrhea, No exanthema, Difficulty in swallowing, not even able to take

liquids easily Cough mild, No history of similar cases in the family Arjun prefers to sleep most of the day.


20

Examination Arjun looks ill, RR 28, HR 110, Sats, perfusion and B.P

normal. Rt tonsil showed a purulent

discharge with inflammation of both tonsils.

Bilateral tender cervical LN++,

Ear and Nose – Normal, Other system examination –

normal


21

“What does Arjun have?” asks the mother. “I had been to a nearby doctor in the morning

and have been prescribed antibiotics, should I continue

it”, she adds?”



22

Diagnosis: Tonsillitis !!!

Your resident doctor then asks you, “how did you decide to use antibiotics here?” The ball is in your

court!


23

Supriyo and Arjun

Supriyo Acute onset, Red

eyes, rhinorrhea, cough, diarrhea, Generalized maculo- papular rashes.

Pharyngeal exudates and cervical lymphadenopathy less common.

Most probably viral

Arjun Explosive onset, throat

pain, rapid progression, very little cough/cold.

Pharyngeal congestion more, thick exudates, ulcers and vesicles, purulent patchy tonsils with tender LN++, Toxicity +++

Most probably bacterial


24

Viral vs Bacterial

Signs with good predictive values Presence of watery nasal discharge Absence of pharyngeal erythema Absence of tender lymphadenopathy Suggest Viral PTL More of these, better the predictability

No single sign is definitive


26

Diagnosis of viral is mainly clinical. Blood count, ESR and C- reactive protein level

can help but have a low predictive value.

Throat culture Gold standard for diagnosing streptococcal

pharyngitis. However cannot diff between carriers and case. Negative throat culture result has a very high

negative predictive value for GAS pharyngitis. Major drawback – lag time of 18-48 hours

Pharyngo-tonsillitis


27

Rapid Antigen Detection tests (RADT) have good sensitivity and specificity, but are expensive and not easily available.

Streptococcal antibody testing (ASO) etc has no role in the diagnosis of acute streptococcal pharyngitis

Is there a simpler way?


28

Your resident then asks you “Why and which antibiotics should one choose ?”

GABHS is self limiting disease recovering within 3-4 days. The goals of

pharmacotherapy are to reduce morbidity and to prevent complications. Complications can be prevented even if the antibiotics are started as late as by the 9th day of illness.


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In children with no Penicillin allergy

Antibiotic (route) (days) Children (< 30kg) Children ( > 30kg)

Penicillin V (Oral) (10d) 250 mg BID 500 mg BID

Amoxycillin (Oral) (10d) 40mg/kg/day 250 mg TID

Benzathine penicillin G (IM) (single dose)

6 lakh Units 1.2 Million Units.

In children with Penicillin allergy (Non type 1)

Antibiotic ( route ) ( days) Children ( < 27 kg)

Erythromycin ethylsuccinate (oral) (10ds) 40-50 mg/kg/day TID

Azithromycin (oral ) ( 5days) 12 mg/kg OD

I generation Cephalosporin (oral) (10ds) Cephalexin / Cefaclor* in usual doses.

II Line: Clindamycin (oral) (10days) 10-20 mg / kg.

*early second generation


30

2 months later, Arjun is back with fever, cough and coryza. See his throat

Doctor considers him to have viral pharyngitis.

DO YOU AGREE?

HERPANGINA


Pharyngeal Erythema but not bacterial


31

Some more non-bacterial inflmn


32

“But doctor” asks the mother “This is the 3rd episode of

tonsillitis that Arjun has had in the past 2 years, and one of my family physicians has advised

tonsillectomy for him.

What is your opinion?



33

Guidelines for considering tonsillectomy

1. 7 or more episodes of tonsillitis in 1 yr.2. 5 or more episodes per year over a 2

year period.3. Enlarged tonsils that create significant

upper airway obstruction.4. An abscess in the tonsils.

Large tonsils like this if not causing any obstruction need

no intervention


34

Management Protocol

Examine eye / ear / nose / body

Conjunctivitis / CoryzaHoarseness / Cough

Purulent / Patches /Toxic / Tender L.Nodes

• Viral ?• Symptomatics (3-4d)

• Bacterial • Antibiotics before

/ after Culture

Responds No Resp.

ResponseFollow up

Culture/RADT

-- ve

+ ve


35

Arjun returns

Arjun, our 6 yr old, returns after 10 days, He has fever & headache for past 3 days.

O/E Purulent Nasal discharge, Slight Periorbital edema with tenderness on percussion on maxillary and frontal sinuses

Diagnosis ?????



36

Arjun has developed Sinusitis


37

When does one suspect sinusitis?

Usually Clinical

Prolonged, upper respiratory signs/symptoms >10-14 days

Severe upper respiratory signs/symptoms (Fever > 1020F, Facial swelling and pain)


38

Classification of Sinusitis Acute Infection<30 days;

Persistent:>14/<30 days; Severe: Temp>102 °F, Purulent

discharge, Sick child.

Subacute:- 30-90 days

Recurrent:-<30 days ;Relapse after 10 days

Chronic :->90 days.


39

Development of sinuses

Maxillary and Ethmoid sinuses

10th wk POG At birth

Sphenoid sinuses

3yrs 8yrs

Frontal sinuses

7-8 years Early teens


40

Predisposing factors

Viral URI Allergic rhinitis and

Nasal Polyps

Nasal Foreign Body Adenoidal

Hypertrophy Nasogastric tube

Cleft Palate GERD

Mucociliary disorders PCD CF Kartageners Syndrome

Immunodeficiency states

Dental infections


41

Common Pathogens Acute and Subacute Sinusitis

Strept. Pneumoniae Non typeable H influenzae Moraxella catarrhalis Strept pyogenes (beta hem)

Chronic Sinusitis Bacterial Pathogens not well defined Polymicrobial infection common Alpha hemolytic Strept., Staph aureus,

CONS, Non typeable H influenzae, Moraxella catarrhalis & Anaerobic Bacteria


42

What are the diagnostic facilities for sinusitis?

Clinical History Examination Radiology Microbiology

Diagnosis of Sinusitis is essentially clinical.


43

X-Rays Abnormal X-Rays-

complete opacification, mucosal thickening of at least 4 mm, or an air-fluid level.

In children below 6 yrs history predicted abnormal sinuses in 88%

In children older than 6yrs history predicted abnormal sinuses in 70%

Technical difficulties to achieve positioning.


44

Guidelines for Diagnosis Radiological

X-rays therefore not needed in most. Clinical correlation is good. X rays recommended if:

Recurrent Complications Unclear diagnosis


45

X-Rays Waters view

Maxillary and Frontal sinuses

Caldwells view- Frontal sinuses seen

well Ethmoid & sphenoid

superimposed.


46

Other views: Open mouth view-Sphenoid sinuses Lateral View Sphenoid Sinus.


47

Management Medical Antibiotics Main stay :

Amoxycillin (40 mg/kg/d) Cefuroxime Co amoxy clav- can be second line if

initial choice was Amoxycillin Select Any of these based on cost and safety

If severe disease or failure to first line drugs: Parenteral Ceftriaxone / Cefotaxime then

may switch to oral Cefopodoxime


48

Management Medical Treat for 10-14 days or 1 week beyond

symptom resolution, which ever is later

In case of persistent non response – imaging and sinus aspiration should be done.

Adjuvant Therapies : Limited Data, Not recommended.


49

Azhar 15 month boy

Azhar, a 15 month otherwise healthy boy had rhinorrhea, cough and fever of 1020F for two days.

On day 5, he became fussy and woke up crying multiple times at night

WHAT COULD BE WRONG?HOW DOES ONE EVALUATE THIS CHILD ?



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CLINICAL EXAMINATION

ENT EVALUATION OTOSCOPE


51

OTOSCOPY FINDINGS AZHAR HAD WAX IN THE EAR.

EAR DRUM COULD NOT BE VISUALISED

WHAT COULD YOU DO?

ATTEMPT TO REMOVE WAX [only if soft] Soft – Curette Hard- Solvent

EMPIRIC TREATMENT In acute phase wax removal can be painful so

empiric therapy may be used


52

THE RIGHT TYMPANIC MEMBRANE WAS RED AND HAD WHITE FLUID BEHIND THE UMBO

THE FOLLOWING DAY HE HAD SLIGHT REDNESS OF THE LEFT TYMPANIC MEMBRANE AND NO FLUID


53

AZHAR HAS ACUTE OTITIS MEDIA RIGHT EAR

Erythema Fluid Impaired mobility Acute symptoms

MANAGEMENT ?



54

Management AOM – Under 2 Yrs

Analgesia Paracetamol in adequate doses as good as

Ibuprofen Decongestants no role Antibiotics in divided doses for 10 days

Choices first line Amoxycillin/ Co-amoxyclav Second line

Second generation cephalosporins e.g. Cefaclor, cefuroxime.

Co amoxyclav – if not used earlier


55

Follow up: Reviewed at 72 hrs

If improving- Continue the antibiotic for ten days

If patient deteriorates Consider changing the antibiotic

Choices are i.m. Ceftriaxone Or third generation oral

Cephalosporins like Cefopodoxime, Cefdinir AND NOT Cefixime as has poor

action against St pneumoniae


56

10th DAY OTOSCOPY

Azhar has improved completely-- general follow up

The patient has no signs of inflammation but dullness and bulging remain in both ears


57

DIAGNOSIS MEE

Middle ear effusion is a common complication following AOM

Seen in younger age groups Management?


58

NO ACTIVE TREATMENT Needs review every two weeks Usually resolves by 12 weeks Tympanometry is helpful in follow-up for

resolution


59

MONICA 7 Yr Old

Monica, a 7 yr old child complains of mild fever, sore throat and discomfort in the left ear for a few hours

She has just started swimming lessons On examination she has mild throat

congestion, rhinitis and an erythematous bulging left tympanic membrane

DIAGNOSIS AND MANAGEMENT ?



60

Management of AOM in >2 yr old

Analgesics Mainstay of treatment

Decongestants have a questionable role Antibiotics

No urgency to start antibiotics unlike a <2 yr old baby

Wait and watch for 48-72 hrs Start antibiotics only if deterioration Drug of choice Amoxycillin 40mg/kg/day in

two divided doses for 7 days


61

Co-amoxyclav

Mild to moderate

< 2yrs

Amoxycillin

> 2yrs

Wait for 48 hrs If worse, Amox

Red drum

Observe

resolve

•Remove wax•Consider

tympanometry•Empiric treatment•ENT consultation

Indeterminate

Red & bulging

Severe disease*

* Severe disease - Explosive onset, Severe Otalgia, Toxicity and High grade fever 1020F+

Background ARI, ear tugging, fever, irritability, otalgia

Otoscopy


62

AZHAR returns

Azhar was lost to follow up comes back to you at 2.5 years of age. The mother says he speaks little while his sister at same age used to speak a lot more. Whatever little he speaks has been unclear and gibberish. He has had 4 episodes of

ear infections in the last six months.He goes to a day care centre and is bottle fed

WHAT IS WRONG WITH HIM?



63

EVALUATION

Deviated septum Snoring Bilateral dull tympanic membranes with

limited mobility Diagnosis? Management?


64

Chronic Middle Ear Effusion

No active signs of inflammation Investigation of choice –Tympanometry Careful follow up If no resolution at 12 weeks

consider grommet /adenoidectomy Removal of risk factors


65

Ambica, a 16 Month Old

This malnourished child is brought with chronic purulent ear discharge of three months duration

Investigations and Management?



66

Chronic Suppurative Otitis Media

Nutrition Combination of oral antibiotics (as

before) and local antibiotics (quinolones) for at least two weeks

Early referral to ENT service

Child with Fever, Cough and Noisy

Breathing

Croup Diphtheria Pertussis


68

Harshad – a child with fever, cough and noisy breathing

2 year old Harshad, presents with 1 day history of mild grade fever and running

nose. His mother also says that his voice has changed and that his cough this time has a peculiar sound which

she has not heard before.

What are the possibilities? What other information one needs?



69

Harshad - Analyzed

Characteristics: Acute onset Fever, running nose and cough – infective

etiology – likely to be upper airway Changed cough character – likely to be

involving larynx Hence an acute upper airway infection –

laryngitis +


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Other information required: Is the child playful? Is the child feeding well? History of similar complaints in the past?

His mother says that Harshad is quite playful and has been eating well. He does not seem to be disturbed by his loud and almost barking cough. He has not had any similar episodes in past.


71

O/E: Harshad is a active playful 2 year old, well nourished. His temp is 990F in axilla.

Ant rhinoscopy reveals rhinitis. His ears and throat are normal.

Harshad does have a barking loud cough, and a high pitched inspiratory noise, particularly after coughing and crying. But is absent during rest.

What could the diagnosis be?



72

Acute viral croup

How should Harshad’s illness be graded?



73

Grading severity of croup

Mild Moderate SevereGeneralAppearance

Happy, Feeds well, Interested in surroundings

Fussy but inter- active. Comforted by parents.

Restless, agitated. Altered sensorium.

Stridor Stridor on coughing and crying. No stridor at rest.

Stridor at rest worsening with agitation

Stridor at rest worsening with agitation

RespiratoryDistress

No distress Tachypnoea, Tachycardia and chest retractions

Marked Tachycardia, with chest retractions

Oxygenation > 92% in room air

>92% in room air

<92% in room air. Cyanosis.


74

Harshad has Mild Croup.

How should one treat Harshad?



75

Croup - TreatmentMild Moderate Severe

SteroidsOral/Nebulized/IM

? Yes Yes

NebulizedAdrenaline

No No (May be given if deterioration noted during observation)

Repeated doses may be required.

Oxygen No No As required to keep SaO2 >92%

ANTIBIOTICS NO ROLE

NO ROLE NO ROLE


76

Harshad has mild croup

Hence Harshad requires symptomatic treatment

Mother may also be advised to give Humidified air inhalation / bathroom steaming

Few authorities may use a single oral dose of Prednisolone / Dexamethasone to decrease the parental stress as well as the risk of return to medical care.


77

Parental advice

Parents to be informed that croup generally gets more severe at nights.

To look out for increasing severity manifested by increasing stridor, increasing breathing difficulty and the child getting increasingly agitated with refusal of feeds.

To come back to medical assistance if severity increases.


78

Harshad’s mother rings you up in the middle of the night because his breathing severity has increased

and she is bringing him to the emergency.

O/E Harshad now has a audible stridor at rest, He is crying and restless but is consolable by parents. His HR 120, RR 26, Sats 92% in room

air. He has minimal intercostals retractions, and has good air entry bilaterally.

Do we need to run tests on him? How should he be treated now?


79

Investigating Croup

Investigations not required in typical croup. Croup is a clinical diagnosis. In a child with airway obstruction, neck

radiographs or blood tests cause anxiety which may precipitate further distress and obstruction.

X-ray AP view of the soft tissues of neck if done – reveals a tapered narrowing (steeple sign)

of the subglottic trachea instead of the normal shouldered appearance.


80

X-ray AP View of neck showing a classical narrowed steeple like tracheal air column at larynx

with a dilate hypo pharynx as seen in Croup


81

Harshad now has moderate croup

Observation for upto 4 hours. Steroids:

If not given before, a dose of oral/nebulized/IM steroid has to be given.

If it is > 12h since previous dose, repeat dose of Nebulised steroid can be given.

Nebulised Adrenaline: Used if symptoms are increasing, and repeated if

clinically indicated (0.5ml/kg of 1:1000 dilution to maximum of 5ml). Routinely available adrenaline is as effective as racemic adrenaline.

If asymptomatic at the end of 4 hrs, he can be discharged.


82

Steroid and Adrenaline Dose

Steroids Repeated doses of 2 mg nebulised budesonide 12h x

48hrs Oral and intramuscular dexamethasone is equally

efficacious Oral corticosteroids are preferred for their ease.

Doses: Dexamethasone 0.15–0.3 mg/kg Prednisolone is 1–2 mg/kg.

Adrenaline Adrenaline is used in severe cases and those poorly

responsive to steroids. Need for repeated doses should alert for the probable

need for intubation/ PICU care.


83

“Why steroids to my child?” Asks Harshad’s mother.

What advice should one send this child home with?



84

Steroids in Croup The use of steroids has been associated

with A reduced average length of stay in the

emergency department. A significant decrease in the number of

adrenaline nebulizations required. A reduced need for endotracheal intubation. If required, the duration of intubation is

decreased. Current evidence more strong for its

efficacy in moderate to severe croup.


85

At the end of 2 hours, Harshad was clearly unwell. He is now non

consolable. His saturations are 84 – 86% in room air and requires 2 lts of

Oxygen by nasal cannula.

How should one treat Harshad?



86

Harshad has developed signs of severe croup Continue Oxygen as required. Admit Continue Nebulised adrenaline as frequently

as needed clinically If adrenaline is required more than 2 hourly, then

he has to be shifted to a place with intensive care facilities.

Steroids to be continued. If airway obstructions/ work of breathing is

worsening, then one has to consider intubation and ventilation. Preferably use a tube half size smaller then optimal.


87

Croup – Key points Croup is essentially a viral illness. No investigations are required in a child with

typical croup Most children with croup develop a mild

illness and do not require any medical assistance.

Steroids are extremely useful and indicated in a child with moderate and severe croup.

Steroids can be given orally, IM or Nebulised and all routes are equipotent.

Adrenaline nebulization is reserved for children with severe croup.


88

Lakhan 2 year old has persistent cough with some noise

Lakhan has been coughing for past 2 weeks or so. He had low grade fever of initial few days.

Gets severe bouts of coughing, more often when the mother is cooking on her kerosene stove.

Few of the times, he becomes totally out of breath and makes a loud sound, which the mother describes as if its coming from a dog.

What more information does one need?


89

Lakhan has Whooping Cough or Pertussis.


90

When should one suspect pertussis?

Any individual (child/ adolescence) with Prolonged (2 weeks or more) paroxysmal

cough With or without whoop/ post tussive

vomiting Irrespective of immunization

Respiratory illness with complications like conjunctival hemorrhages, fractures, rectal prolapse or encephalopathy,


91

Paroxysmal cough is an essential criteria Even partially immune individuals retain this

Typical paroxysm : A series of rapid, forced expirations (usually 5-10), followed

by gasping inhalation, leading to the typical whoop. Cyanosis, bulging eyes, protrusion of the tongue, salivation,

lacrimation and distension of the neck veins occurs Post-tussive vomiting is common. Can occur several times per hour during both day and night triggered by yawning, sneezing or physical exertion.

Whoop and post tussive vomiting component of the paroxysm may not be found in the partially immune- therefore not essential for diagnosis


92

How to confirm the diagnosis ? CBC

Absolute lymphocyte count > 10,000/ l ALC above age specific mean has 70% sensitivity Normal count does not exclude pertussis Neonates may have much higher counts

CXR Not sensitive or specific Role of cultures - not of practical importance Serology and PCR Not recommended

routinely Diagnosis usually clinical aided by CBC


93

Treatment Antibiotics

• Reduce transmissibility• May reduce symptoms if given in 1st week• Limited role as usually diagnosed later

Gentle suction for removal of secretions Avoidance of cough provoking factors Humidified oxygen and assisted ventilation if required

Dose & Duration Status

Erythromycin 40-50 mg/kg/day q 6 hrly X 14 days

Side effectsDuration/ adherenceNot < 1 month

Clarithromycin 15 mg/kg/day Q 12 hrly X 7 days

ExpensiveDrug interactionNot < 1 month

Azithromycin < 6 mths:10 mg/kg/day X 5 d> 6 mths: 10 mg/kg on day 1 and 5 mg/kg day 2-5

CheapNo drug interactionsCan be given < 1 mth

Cotrimoxazole 8 mg/kg of TMPQ 12 hrly X 14 days

Intolerant/CI of macrolides

Azithromycin is DOC considering all factors


94

Treatment- Supportive

Not of any benefit Antihistaminics Steroids Salbutamol Pertussis immunoglobulin


95

Un-immunised child, has difficult noisy breathing x 2d

Mother reports mild moderate grade fever and sania is very lethargic and dull for 1 day.

Mother also feels that her neck is swollen. O/e

Temperature 1000F Laboured noisy breathing Diffuse swelling of her neck. Throat examination : a greyish white membrane over

the pharyngo-tonsillar area and beyond. The membrane bleeds on touch and is difficult to remove

Sania, 4 year old female child


96

What is Sania likely sick from?

Sania probably has Diphtheria

http://www.idph.state.il.us/about/immunepics/diphtheria2.htm



97

Suspecting diphtheria : Sore throat with membrane in tonsillopharyngeal

area Fever, hoarseness, barking cough, stridor,

membrane over pharynx and larynx Sero-sanguinous nasal discharge, crusts and a

white membrane on septum Late Presentations : may not be any visible

membrane Palatal or bulbar palsy Myocarditis with prior sore throat Acute polyneuropathy with or without prior sore throat.

May occur even in previously immunized

Confirming diphtheria Smear and culture of the membrane or scraping

below the membrane Stain with Neisser or Albert stain


98

How will you treat Sania?

Hospitalization in infectious disease facility Droplet isolation till three consecutive daily

cultures are negative Start treatment without waiting for

microbiologic culture confirmation Components of therapy

Diphtheria antitoxin (DAT), most crucial Antibiotics Supportive care Management of complications


99

Treatment - DAT

Always administer test dose

If allergic desensitize Full dose given IV at one

time, diluted in NS (1:20), rate of 1 ml/minute

Limited availability at ID hospitals

Serum sickness in 10% patients

Type Total dose in units

Nasal 10,000- 20,000

Laryngeal/ Pharyngeal

20,000- 40,000

Tonsillar 15,000-25,000

Combined types/ delayed diagnosis

40,000-60,000

Severe disease* 80,000 –100,000

Carrier/ Contact Not required

*extensive disease/ more than 3 days duration/ neck edema/tachycardia/ collapse/ breathlessness


100

Treatment continued

Antibiotics (Penicillin G/ Procaine penicillin/ Erythromycin for 14 days)

Strict bed rest for 2- 3 weeks Adequate nutrition and hydration Steroids not recommended Carnitine 100 mg/kg/day BD for 4 doses

may help prevent myocarditis Complete immunization on recovery

Child with Fever, Cough, and Rapid &

Difficult Breathing

BronchiolitisCommunity Acquired PneumoniaNosocomial PneumoniaRecurrent PneumoniaEmpyemaBronchiectasis


102

Luv AND Kush are 3 month old twins who were born at 34 week of gestation. Luv was oxygen dependent for 4 days after birth and has been doing well since then. Kush required ventilation for 6 days after birth and was off oxygen after Day 16 of age, and has been well since. No other neonatal problems.

They were brought to the clinic with 4 day history of fever, cold and cough. Kush also had history of refusal of feeds since the past 8 hours.


103

Luv O/E: RR 60/min, HR 130/min, Pink, well

perfused, Saturations 96% in room air, Active, interested in surroundings. Minimal sub coastal in drawing, Good air entry bilaterally, occasional rhonchi++. Other systems – normal.

“What does my child have?” asks the mother



104

Features: Young, well looking infant Tachypnea++ Tachycardia++ Saturating well Bilateral scattered wheezeMost likely diagnosis: Bronchiolitis

How severe is it? Asks the mother



105

Grading bronchiolitisMILD MODERATE SEVERE

FeedingAbility

Normal Ability to feed

Appear short of breath During feeding

May be reluctant or unable to feed

RespiratoryDistress

Little or no respiratory

distress

Moderate distress with some chest wall retractions and nasal flaring.

Brief self limiting apnoeas

Severe distress with marked chest wall retractions, nasal flaring and grunting.

Can have frequent and prolonged apnoeas

SaturationsSaturations

>92%

Saturations <92%, correctable with O2

Saturations <92%, may or may not be

correctable with O2


106

“Luv has mild bronchiolitis”, I explained to the mother.

“What medications do I need to give him?”, she asked.



107

Bronchiolitis - Treatment

Mild Moderate Severe No

treatment required.

Reassure mother.

To bring the baby back if distress increases

Admit Humidified oxygen to

maintain sats > 92% IV fluids Observe for deterioration If the child deteriorates

treat as severe

Admit – ICU care O2 to maintain sats >92% IV fluids Cardio respiratory

monitoring ABG/CXR Assess need for

ventilatory support / ICU care


108

Kush O/E: Febrile 101º F , RR 80/min, HR

150/min, sats 88% in room air, crying incessantly, dry paroxysmal cough, supra sternal and sub coastal in drawing++, hyper inflated chest, bilateral rhonchi and scattered creps++, Liver and spleen just palpable below coastal margins. Other systems normal.

What are the diagnostic possibilities?


109

Most likely diagnosis – bronchiolitis Differential diagnosis:

Pneumonia GERD with aspiration Foreign body Congenital heart disease Congenital anomalies like vascular ring

How should Kush’s severity be graded?



110

Grading bronchiolitis

Mild Moderate Severe

No treatment required.

Reassure mother.

To bring the baby back if distress increases

Admit Humidified oxygen to

maintain sats > 92% IV fluids Observe for deterioration If the child deteriorates

treat as severe

Admit – ICU care O2 to maintain sats >92% IV fluids Cardio respiratory

monitoring ABG/CXR Assess need for ventilatory

support / ICU care


111

“Why my babies?” asked the mother. “Why are both of them affected? Is their resistance poor? Is it because they were preterm babies?”

What are the children at high risk of disease and increased

severity?



112

Bronchiolitis – Risk factorsAn increased risk severity and of bronchiolitis related hospitalization seen in following:

Infants in day care Exposure to passive smoke Crowding in the household Infants younger than 2 – 3 months Premature birth < 34 – 37 weeks Congenital heart disease Chronic Lung disease like CF, Recurrent aspiration,

BPD, Congenital malformations etc Immunodeficiency Hypoxia


113

“Luv is fine and I can handle him at home, but Kush is not feeding. How do I handle him? Do I

treat him differently? I do not think I can manage the two separately one at home and

other here”.

How should Kush be managed? – Discuss What are the indications for admitting a

child with bronchiolitis?



114

Bronchiolitis - Treatment

Mild Moderate Severe

No treatmentrequired. Reassuremother.To bring thebaby back if distressincreases

AdmitHumidified oxygen tomaintain sats > 92%IV fluidsObserve fordeterioration If the child deteriorates

Admit – ICU careO2 to maintain sats>92%IV fluidsCardio respiratorymonitoringABG/CXRAsses need forventilatory support / ICU

care


115

Bronchiolitis – Indications for hospitalization

Infants younger than 3 months Oxygen saturation < 92% RR > 70/min ILL appearing child Infants with one or more risk factors

mentioned before are likely to have a severe course and merit admission.


116

So, you explain to the mother that Kush needs admission for observation and treatment and she agrees.

Your resident doctor who is now going to take care of the admission and in-house management asks you, “ Sir, He is wheezing a lot. Can I do a Chest x-ray and blood tests? Can I also start him on Salbutamol/adrenaline nebulizations, and IV steroids too?”

KUSH


117

Bronchiolitis - Investigations

Bronchiolitis is a clinical diagnosis. Investigations contribute very little. CXR may be indicated in

severe respiratory distress or in case of a diagnostic uncertainty.

X-ray often reveals bilateral hyperinflation, findings like segmental atelectasis may be seen

some times Blood tests do not contribute.


118

The resident doctor is very confused about the management of bronchiolitis. But he is not to be blamed, since there is so much controversy regarding the

role of various medications in bronchiolitis.

What is the rational management for Kush?


119

Bronchiolitis - Management

Non Controversial Oxygen IV fluids

Controversial Adrenaline nebs Bronchodilators Steroids Antibiotics


120

Bronchiolitis - Fluids Oral feeding,

if tolerated well, should be continued in infants with no more than moderate respiratory difficulty (respiratory rate < 80 breaths per minute, some chest-wall retraction, and maintaining an Spo2 > 92% in supplemental oxygen)

Intravenous fluids should be administered when there is moderate to

severe or severe respiratory difficulty (marked chest wall retraction, nasal flaring, expiratory grunting), marked tachypnoea (> 80 breaths per minute), apnoeic episodes, or visible tiring during feeds.


121

Bronchiolitis - Fluids Considerable variation in the intravenous

hydration strategies recommended Normal general maintenance IV fluids are

used. Nasogastric tube feeding

Generally reserved for the recovery phase because: NG tubes blocks one nostril thereby increasing

the airway resistance and work of breathing. Feed in the stomach also compresses the

diaphgram and increases the risk of reflux and aspiration.


122

Bronchiolitis – Oxygen

The use of supplemental oxygen therapy has not been subjected to randomized controlled clinical trials,

Use is considered appropriate to overcome hypoxemia.

In general, maintain an SpO2 ≥ 92% saturation

during the acute phase and during recovery, Can accept 90% to 92%SpO2, if the child is not

distressed and is feeding well.


123

Bronchiolitis - Bronchodilators

There is no role for routine bronchodilators in bronchiolitis as they do not: improve oxygen saturation, affect rate or duration of hospitalization.

A trial of Nebulised bronchodilator can be given in: older infant (>6 months) with wheeze, with a

strong history of atopy, further therapy continued if there is a objective

improvement.


124

Bronchiolitis - Steroids

Multiple studies have failed to demonstrate any clear efficacy of corticosteroids in viral bronchiolitis.


125

Bronchiolitis - Adrenaline Very little support from randomized

clinical trials to the use of adrenaline in all children with moderate/severe bronchiolitis.

The improvement in respiratory symptoms across studies has been inconsistent and short lived.

May use Nebulised adrenaline as a potential rescue medication for those who are to be admitted.

Dose varies between 0.01ml/kg to 0.3ml/kg per dose of 1:1,000 solution.


126

Bronchiolitis - Antibiotics

RCTs failed to demonstrate any benefit in hospitalized infants with bronchiolitis.

The only role for antibiotics is: complicated bronchiolitis where a secondary

bacterial infection is suspected. This is rare, but not easily excluded in a sick

infant with fever, toxicity and significant opacities on the chest radiograph.


127

Bronchiolitis -sedation Sedatives should be avoided Irritability may be a sign of Hypoxia Sedatives can decrease the oxygenation as

well as give a false sense of relief No safe sedative Attempt to comfort the child as far as possible

Fever control Nasal clearing Feeding Non threatening manner of oxygenation/ nebulisation


128

VIRAL BRONCHIOLITIS

Mild bronchiolitis• Normal ability to feed• Little/no resp. distressNot hypoxemic

Moderate bronchiolitis Moderate resp. distress Mild hypoxemia +/- brief

apnea +/- short of breath

Severe bronchiolitis Severe resp. distress +/-

apnoeic episodes +/-hypoxemic

Looking tired Can’t feed

Does not need investigations

Home treatment

Admit Humidified O2 to maintain

SaO2 above 92% IV fluids Observe for deterioration

Admit- ICU care O2 to maintain SaO2 above 92% IV fluids Cardio respiratory monitoring ABG, CXR Assess need for - ventilatory

support/ ICU care

Improvement• Decrease O2 [guided by SaO2]• Re-establish feeding• Discharge when distress

decreased and feeding well

DeteriorationTreat as severe bronchiolitis


129

Kush was treated with IV fluids and oxygen supplementation. He improved with 3 days.

His mother now feels that he is comfortable and wants to take him home.

What would your opinion be? What would be your discharge

criteria for bronchiolitis?

Discharge criteria An infant is considered ready for discharge if

he or she had: Not received supplemental oxygen for 10 hours. Minimal or no chest retractions Feeding adequately without the need for IV

fluids.


130

Parnami, 3 year old female Presents with an acute history of fever, cough

for 3 days She is irritable and has significant cough The parents are worried because the local

practitioner has told them that Parnami has pneumonia and should be admitted. They seek your opinion.

What will you look, hear or investigate to confirm the diagnosis?



131

Most consistent clinical sign of pneumonia

Age Respiratory rate (breaths/min)

< 2 months 60 or more

2 months upto 12 mo

50 or more

12 months upto 5 years

40 or more

WHO recommends using these Respiratory rate cutoffs to diagnose pneumonia

at the community level


132

Parnami has a respiratory rate of 48/min

She has tachypnoea and a RR higher than the age specific cutoffs endorsed by WHO,

Dr Padma, your resident says “Does this mean she has pneumonia? This is simple and I can use this in my OPD screening too”.

Is she right?

Age Respiratory rate (breaths/min)

< 2 months 60 or more

2 months upto 12 months

50 or more

12 months upto 5 years

40 or more


133

Tachypnoea

A sensitive and specific tool – 66% approx as good or better than auscultation for pneumonia

But there are several clinical situations which can cause rapid breathing e.g. Wheezing –asthma/bronchiolitis/WALRI

Non pulm causes like metabolic acidosis, CHF, raised ICT can also cause tachypnoea

A clinician must use this merely as a beginning step.

Use all clinical skills for making a final conclusion.


134

Child with Cough, Rapid, Difficult breathing Consider Bronchiolitis-VAW if:

Age 1mo -1yr Presence of Upper respiratory catarrh Progressive increase in resp distress

(tachypnoea, retractions) Wheeze + crackles Clinical and radiological evidence of

hyperinflation


135

Child with Cough, Rapid, Difficult breathing

Consider LTB-Croup if: Hoarseness of voice and barking/brassy

cough Stridor Mild to marked respiratory distress Sonorous rhonchi Fever usually mild or spiking (tracheitis,

rare)


136

Child with Cough, Rapid, Difficult breathing Consider Asthma if:

Recurrent episode, 3 or more Wheeze Good response to bronchodilator Hyperinflation Family/personal history of atopy


137

Can viral or bacterial pneumonia be clinically distinguished

Perhaps, No All of the following studied and not

found useful Presence of wheeze ESR CRP COUNTS CXR findings

Advantage of using the current methodology- decreases the confounder to viral pneum alone rather than broad ALRTI


138

Dr Padma is now fully convinced. She says, “Now I know that simple clinical tools used judiciously can differentiate between different causes for cough and rapid breathing. And therefore help us be rational in management.”

But Sir, A. How do I confirm the

diagnosis? and if I have to use the correct antibiotics,

B. How can I suspect or confirm the probable organisms?”


139

DIAGNOSIS RADIOLOGICAL

Do all patients require a chest radiograph?

NO, Not all CAP, particularly if on domiciliary

treatmentFew -Yes,

If complication suspected (for example, pleural effusion)

Ambiguous Clinical features


140

MICROBIOLOGICAL

• Not recommended routinely• Takes a long time and hence has

limited utility• Sputum cultures / cough swabs have

relatively poor reliability• Invasive methods can not be justified

for routine pneumonias.


141

Role of pulse oxymetry, acute phase reactants, etc. in pneumonia

Routine microbiological tests are of no use.

TLC, DLC, CRP are not diagnostic but may be useful to monitor the response to treatment.

Pulse oxymetry is a good tool for assessing the severity and for monitoring response in those with severe disease.


142

QUESTIONS?????

In the absence of a microbiological diagnosis in most cases, How does one know which bacteria is the offending organism?

Are there any other supportive evidences for the probable etiology?


143

Proportion of cases attributable to different etiological agents

2-60m age Viruses- 35% Bacteria- 60%

H influenzae Strep pneumo Staphylococci Mycoplasma – 24-30% More in above 5 years

Chlamydia- 6-11% Mixed infections- 9%


144

0-3 months Gram Negative St pyogenesChlamydiaViruses

3mo-5yrs Str pneumoniaeH InfluenzaeStaph aureusVirusesMycoplasma pneum

>5 yrs Str pneumoniaeStaphylococcusVirusesMycoplasma pneumSt pyogenesH Influenzae

Age related Pathogens involved in Community Aq Pneumonia


145

Defining Community Acquired Pneumonia

Community acquired pneumonia is an acute infection of the pulmonary parenchyma in a previously healthy child, acquired outside of a hospital setting. The patient should not have been hospitalized within 14 days prior to the onset of symptoms or has been hospitalized less than 4 days prior to onset of symptoms.


146

What it excludes

Child with any immune-deficiency Severe Malnutrition Post measles state

Ventilator assoc Pneum Nosocomial spread Recurrent – which one??


147

Reliability of predicting a special etiological agent based on clinical features and/or radiography

Generally POOR ONE EXCEPTION - STAPH

More likely if Very rapid progression Skin Lesions, infected scabies PE/ Pneumothorax/ empyema ?post measles


148

Parnami

On detailed examination, she has tachypnoea, no cyanosis or diaphoresis. She is conscious but irritable.

She has significant lower chest retractions and flaring of the alae nasi.

How bad is she? How should she be treated?



149

Assessing severity

WHO classification useful Severe:

Tachypnoea with accessory muscles working Very Severe:

Tachypnoea with accessory muscles working AND

Altered sensorium, orCyanosis, orDifficulty in feeding, orPoor perfusion, etc


150

Mild Severe

Infants

• Temperature < 38.50C RR < 50 breaths/min Mild recession Taking full feeds

• Temperature > 38.50C RR > 70 breaths/min Moderate to severe recession Nasal flaring Cyanosis Intermittent apnea Grunting respiration Not feeding

Older children • Temperature < 38.50C RR < 50 breaths/min Mild breathlessness No vomiting

• Temperature > 38.50C RR > 50 breaths/min Severe difficulty in breathing Nasal flaring Cyanosis Grunting respiration Signs of dehydration

Severity Assessment


151

Indications for admission to hospital in infants: SaO2 < 92%, cyanosis respiratory rate > 70 beats /min and difficulty in breathing intermittent apnea, grunting not feeding; family not able to provide appropriate observation or

supervision. Indications for admission to hospital in older

children: SaO2 < 92%, cyanosis; respiratory rate > 50 breaths / min; difficulty in breathing grunting signs of dehydration family not able to provide appropriate observation or

supervision.


152

Supportive therapy for CAP

Oxygen : as indicated by pulse oxymetry and/ or clinical signs of hypoxia like rapid breathing as well as

retractions

IV Fluids: If dehydrated, Tachypnoea severe enough to make the child unable to drink,

or impending respiratory failure.

Fever management Important as fever increase oxygen requirement Paracetamol and sponging are useful in most situations.

Bronchodilators, where indicated should be used to decrease the work of breathing.

Chest Physiotherapy helps in preventing atelectasis.


153

Disease Pneumonia

Setting Domicilliary

AGE First Line Second Line Suspected Staphylococcal ds

Upto 3mo

Usually Severe, treated as inpatients

3mo- 5yrs of

age

Amoxycillin Co-amoxy clavulinic acidORChloremphenicol

CefuroximeOR

Co-amoxy clavulinic acid OR

Amoxycillin+ Cloxacillin*

5 yrs plus

Amoxycillin MacrolideORCo-amoxy-clavulinic acidORChloremphenicol

CefuroximeOR

Co-amoxy clavulinic acidOR

Amoxycillin+ Cloxacillin*

*Use Separately as combinations available are not scientific


154

Severe – Very Severe PneumoniaTreat as In-patient

Age First Line Second Line

0-3 mo Inj 3rd Gen Cephalosporins:Cefotaxime/Ceftriaxone

+ Aminoglycoside (Gent/Amika)

Inj Co-amoxy clavulinic acid +

Aminoglycoside (Gent/Amika)

3mo-5 years Inj AmpicillinOR

Inj ChloremphenicolOR

Inj Ampicillin +Inj Chloremphenicol (<2 years of age)

ORInj Co-amoxyclavulinic acid

Inj Co-amoxy clavulinic acid OR

Inj 3rd Gen Cephalosporins:Cefotaxime/Ceftriaxone

5 years + Inj AmpicillinOR

Inj ChloremphenicolOR

Inj Co-amoxyclavulinic acidOR

Macrolides (if Mycoplasma suspected)

Inj Co-amoxy clavulinic acid OR

Inj 3rd Gen Cephalosporins:Cefotaxime/Ceftriaxone

ANDMacrolides


155

Severe- Very Severe Disease

SUSPECTED STAPHYLOCOCCAL DS

Inj 3rd Gen Cephalosporins: Cefotaxime/Ceftriaxone

+ CloxacillinOR

Inj CefuroximeOR

Inj Co-amoxyclavulinic acid

Second line: Vancomycin/ Teicoplanin +

Inj 3rd Gen Cephalosporins


156

Issues for severe disease

All parenteral drugs to begin with How Long? Step-down/ switch therapy

3rd generation oral like Cefopodoxime [NOT Cefixime]

Fluoroquinolones not recommended


157

Duration of therapy

Domiciliary 5-7 days If admitted: Switch to oral after 48-72

hrs or earlier if can accept orally. Total 5-7 days

If on second line then IV for 7-10days If Staph.:

2 weeks if no complication; Else 4-6 weeks


158

Parnami

While on treatment, Parnami deteriorates on 5th day of treatment

Her X-ray shows progression of her disease to the other lung as well.

She is very distressed, has irregular breathing and has cyanosis

Should she be shifted elsewhere?



159

INDICATIONS FOR TRANSFER TO PICU

Transfer to PICU should be considered when: failure to maintain SaO2 >92% in FiO2 >0.6 shock rising respiratory and pulse rates with

clinical evidence of severe respiratory distress and exhaustion with or without raised Paco2

recurrent apnea or slow irregular breathing.


160

Does She have Nosocomial Pneumonia?

Possibilities are: Progression of Existing Disease,

Early Hospital Acquired Pneumonia


161

Defining Hospital Aq Pneumonia

HAP - Hospital Aq Pneumonia Pneumonia that occurs 48 hours or more

after admission, which was not incubating at the time of

admission. Managed in a hospital ward or ICU as per

severity

VAP – Ventilator associated Pneumonia Pneumonia that arises more than 48–72

hours after endotracheal intubation


162

Further definitions are needed Early-onset HAP and VAP,

defined as occurring within the first 4 days of hospitalization,

usually carry a better prognosis, and are more likely to be caused by antibiotic

sensitive bacteria.

Late-onset HAP and VAP (5 days or more) more likely to be caused by multidrug-resistant

(MDR) pathogens, associated with increased patient mortality and

morbidity.


163

• Piperacillin tazobactam/ cefoperazone sulbactam with

an aminoglycoside or Fluoroquinolone• Add vancomycin/ linezolid if MRSA suspected

P. aeruginosaAcinetobacterMRSA

Nosocomial pneumonia after 4 days of hospitalization

• Ceftriaxone/ cefotaxime with a macrolide

S. pneumoniaeH. influenzaeS. aureusRespiratory

virusesMycoplasma

Nosocomial pneumonia in first 4 days of hospitalization

Treating Nosocomial Pneumonia


164

Chelsea

4 yr female Fever 5 days, cough since 3days Pain chest, difficulty in breathing – 1 day

Febrile, RR 46/mt, no distress AE Rt side lower zone Diagnosed as pneumonia and put on

oral Amoxycillin


165

Preliminary investigations

CBCHb 11.2, TLC 41,400, P 62 L17 band cells 7CXRRight Lower lobe pneumonia


166

Case Contd.After 48 hrs, Fever persists. Develops increasing respiratory distress,

Chest pain. After 72 hrs,still no response.

What is the likely diagnosis?

Any other clinical information one needs?

What investigations should be ordered?



167

Question to the clinicianWhat is the likely diagnosis?

Complication Progression- non response Phlebitis Co-infection

Any other clinical information one needs? Any predisposing factor – immune suppression H/o Contact with TB case New Signs including Chest Signs

What investigations should be ordered? CBC, X-ray, Quantitative CRP(?)


168

Chelsea

Rt Lower Lobe Pneumonia with effusion.

H/o Pyoderma, Measles,


169

Further Investigations advised

Pleural tap- routine, gram stain Culture Latex agglutination test

Blood culture Ultrasonography


170

Chelsea

Pleural fluid WBC 2400/cumm; 19% polys, 72% lymphos RBC 0.25 million Protein 4.9 gm% Sugar 25 mg% Gram stain: gram positive cocci, no AFB Latex negative C/s awaited

Blood culture awaited


171

What is Empyema?

Presence of pus /micro organism in pleural fluid.

3 stages Exudative (24-72 hrs) Fibrino-purulent (7-10 days) Organizing (>10 days)


172

What are the common bugs?

Streptococcus pneumoniae Staphylococcus H. influenzae Grp A Streptococcus Klebsiella Mycobacterium tuberculosis


173

When to suspect Empyema?

Fever, chills, dyspnea, rapid breathing, chest pain, cough

No response to antibiotics/ worsening after 48 hrs of initiation in cases of pneumonia

Post measles state Co existing staphylococcal skin

infections, boils, arthritis, pyomyositis, etc


174

How to confirm ?

Pleural Fluid AnalysisPurulent fluid pH<7.1, Glucose <40, Proteins>3g/dl, LDH>1000 IU/L

• X Rays USG- Size, site, loculations, adhesions

(Echoic) CT- Little role


175

Recapitulating Chelsea’s results of investigations

Pleural fluid WBC 2400/cumm; 19% polys, 72% lymphos RBC 0.25 million Protein 4.9 gm% Sugar 25 mg% Gram stain: gram positive cocci, no AFB Latex negative C/s awaitedBlood culture awaited


176

Question to the clinician????

Why is there is lymphocytic predominance if it is bacterial Empyema? Partially treated case

Can this be mycobacterial empyema ? Unlikely, short acute history, no

epidemiological clues

How should one manage this case?


177

How to Treat?

Antibiotics WITH

Intercostal drainage (ICD) ICD plus Fibrinolytics Video assisted thoracic surgery (VATS) Open decortication Rib Resection/thoracoplasty/Lobectomy


178

Antibiotics Co amoxyclav

or Cloxacillin with ceftriaxone If no response or resistance based on

cultures second line drugs>7 days. Vancomycin / Teicoplanin, Linezolid plus

ceftazidime. Duration

I.V till afebrile/removal of tube usually 7-14 day Total for 4-6 wks


179

4.

Escherichia coli and Klebsiella

4.

Cefotaxime as in A 2.a

5.

Pseudomonas

5.

a.

Ticarcillin 200-300 mg/kg in 4-6 doses or

b.

Ceftazidime 125-150 mg/kg in 3 doses with

c.

Tobramycin 5-7 mg/kg in 3 doses.

B.

Anaerobic bacteria

1.

B. fragilis

1.

Clindamycin 24-40 mg/kg in 3-4 doses

2.

All except B. fragilis

2.

a.

Same as B.1 or

b.

Penicillin G as in A 3

•Insertion of a chest tube: the site is selected in the mid-axillary line in the 5th intercostal space on the superior aspect of the 6th rib in the “safe triangle”

Ultrasonographically guided insertion found to be effective.

•May Seek help from pediatric surgeon.

Forgotten art


180

Post tube –thoracotomy care

Keep the system patent.

Keep the system airtight.

Maintain sterility of the system to avoid

introducing bacteria into the intrapleural space.

Drain should be clamped for 1 hour once 10

ml/kg are initially removed

Dependent drainage


181

Patients should perform as much activity

as can be tolerated.

Encourage the facilitation of deep

breathing and airway clearance.

Use analgesics on an individual basis to

facilitate airway clearance.


182

Do not do this.

.


183

When to remove ?Timing of elective removal essentially a clinical

decision Amount of fluid draining No Bubbling Child’s temperature General well being CXR and USG appearance Fall in acute phase reactants. (BTS Guidelines, Thorax

2005)

It is not necessary to wait for complete cessation of drainage- accept small drainages like upto 30-50ml/day. But no air leak should be there.


184

What is the role of Fibrinolytics ?

Streptokinase, Urokinase, Alteplase Recommended by some for a shorter stay in

hospital Complicated parapneumonic effusion (thick fluid

with loculation). No evidence that any of the three is more

effective Mainly in UK, studied in a randomized controlled

trial in children so is recommended by BTS. UK :40.000 U in 40 ml NS > 10 kg

10,000 U in 10 ml NS < 10 Kg. 4 Hrs Dwell time needed


185

ComplicationsHemorrhage

Fever

Pleural pain

Arthralgia

Headache

Hypoxemic resp failure

Anaphylaxis

Antigenic response (streptokinase)

UK adhesion VATS difficult.


186

Surgery – when and what?

Failure of treatment and collection of fluid >10 days

Modalities VATS Open thoracotomy and debridement Mini Thoracotomy and debridement


187

Video assisted Thoracoscopy

Primary /secondary• Primary VATS if patient presents late (>7 days

history) or if there are loculations on imaging studies

Secondary VATS when std therapy fails.

Advantages• Early recovery & resolution of empyema

comparable to open decortication. • A viable solution, decreases the stay but not

easily available and not as cheap


188

Long term outcome - Conservative treatment

Satish et al: Decortication and ICT drain no

difference on long term outcome

Pleural thickening has a benign course and

capacity to resolve better in children due to

inherent elasticity of both thoracic cage and lung

tissue.

Patients tested had lung function

between 80% to 100% of predicted Satish et al. Arch Dis Child 2003 Satpathy et al. I J Ped 2005

Recurrent Pneumonia


190

Amit is a 3 year old who is brought for fever and a rapid respiratory rate since 3 days.

On examination he has a grunt and a respiratory rate of 44/min.

On auscultation he has an increased vocal resonance in the right mammary and infra mammary area.

Diagnosis ?

What are your thoughts? The ball is in your court!


191

His X ray shows……


192

Amit contd….

‘ Not again ‘ says his mother. He had a pneumonia three months ago . Here are his X rays ……….


193

Recurrent pneumonia

‘ At least two episodes of pneumonia occurring in one year or three episodes over any period of time.’


194

Amit’s story contd…

“Dr, last time it was in the left lung and now it is in the right lung. Is it part of the same problem?”

Any comments?



195

Key message

Recurrent Pneumonia is a symptomsymptom of an underlying disease and not a diagnosis in itself .

Causes include Commonest-

Asthma, Aspiration syndromes Less common-

Congenital anomalies, FB, CVS shunts, TB, tumors Not infrequent

CF, Immunodeficiencies, ciliary dyskinesias


196

Key points on history Age at onset/ First documented pneumonia Delayed cord fall History suggestive of aspiration or setting

for aspiration (choking, nasal regurgitation, recurrent seizures, dysphagia)

Temporal relation of cough to feeding or posture

Family / personal history of atopy, nocturnal cough, bronchodilator relief


197

Key points on history contd..

Choking while eating a nut or similar object in the past

Consanguinity Family History Multiple multifocal infections e.g. diarrheas ,

pyoderma, ear infections Malabsorptive stools Contact history


198

Key points on examination.

Oropharyngeal examination Clubbing Other features of atopy e.g. flexural

dermatitis Failure to thrive, BCG scar, tonsil size Pallor, generalized adenopathy Perforative otitis media Cardiovascular system Respiratory system


199

How should one approach Amit’s problem?

Are the past symptoms both upper and lower respiratory or only lower respiratory ?

Same lobe at every episode or different lobes?


200

Key message

Upper and lower respiratory Asthma Immunodeficiency Ciliary's dyskinesia CF

Only lower respiratory Aspiration

syndromes Congenital

anomalies CVS shunts FB TB Tumors


201

Recurrent Pneumonia

SAME LOBE Foreign body Tuberculosis Congenital

Anomaly

DIFFERENT LOBES

Aspiration Asthma CVS shunt Mucociliary defects

Immunodeficiencie

s


202

Amit

Amit has had several episodes of otitis media, diarrhea and recurrent pneumonia in different lobes

He tends to get sudden severe infections at various sites, which need intense antibiotic treatment

On Investigation is found to have primary immune deficiency :Agammaglobulinemia


203

Cough with expectoration: likely possibilities

Bronchiectasis (Long standing history) Lung abscess (Relatively shorter

history) Bronchitis (More commonly seen in

adults)


204

Payal a 8 year old girlpresented with persistent cough and expectoration with intermittent increase in the symptoms. She requires a course of antibiotics each time.

X ray film of payal

1. What are likely possibilities?

2. What all questions should be asked to ascertain the diagnosis?


205

Suspected suppurative lung disease: Ask

Past history of pneumonia, pertussis, measles, foreign body inhalation and tuberculosis (Post infectious bronchiectasis)

Infection in other parts of body (Immune deficiencies)

Family history of similar illness, sib death (Immune deficiency, cystic fibrosis, primary ciliary dyskinesia)

History of mal-absorption and failure to thrive (Cystic fibrosis)


206

Suspected suppurative lung disease: look for

Respiratory difficulty: RR, chest indrawing, accessory muscles

Clubbing and crepitations


207

Payal gave history of onset of illness since early infancy, she was passing stools very frequently, her stools were foul smelling and bulky, despite good appetite she was not growing well.

There was family history of sib death who did not pass stool at birth and died after 3 days

She had cystic fibrosis: confirmed by sweat test and mutation analysis.


208

Investigations for bronchiectasis

Radiology Findings on X-ray of chest findings are

nonspecific. Look for the following in the lung parenchyma: ring like densities with clear centre parallel linear lines mimicking rail track irregular ill-defined vascular markings or unequal aeration due to atelectasis and

hyperinflation X-ray of para nasal sinuses picks up

associated sinusitis in few cases.


209


High resolution computerized tomographic scan (HRCT) of chest: Very sensitive and non invasive method The findings include

air fluid levels in the distorted bronchi linear non tapering airways distended bronchi in periphery and thickened bronchial walls

Microbiological Studies Sputum culture/ bronchoalveolar lavage may be tested. Isolates and their sensitivity will help in selection of

antibiotics.


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Causes of bronchiectasis

CONGENITAL ACQUIRED Gross structural defects

o Tracheomegaly

o Bronchomalacia

o Pulmonary sequestration

Ultrastructural defects

o Primary ciliary dyskinesia

Metabolic defects

o Cystic fibrosis

o Alfa-1-antytrypsin

deficiency Immunodeficiency

o Hypo-gammalobulinemia

Infections o Pneumoniao Measles o Tuberculosis

Obstructiono Foreign bodyo Enlarged node

Disorders of immunity/ Allergyo Allergic broncho- pulmonary Aspergillosis

(ABPA) o Autoimmune disease


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Pulmonary function tests Further Investigations are indicated for the

underlying cause. The cause remains unknown in 30-50 % of patients. Needed investigations are :

F O Bronchoscopy, HRCT or bronchography, serum immunoglobulin levels, Gastro esophageal reflux studies, tests for tuberculosis and fungal infections studies for ABPA Sweat chloride, and Ciliary's studies


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Begin general measures (Antibiotics, physiotherapy, adequate nutrition)

Presumptive diagnosis(Based on clinical features and radiographic changes)

Etiology found No etiology found

Institute specific therapy as indicated Continue general measures

Continue general measures

Etiologic evaluation

Close follow up

Improvement/ Stabilization No improvement/Deterioration/Frequent exacerbations

Chest CT/Bronchography Continue general measures Periodic monitoring

Resectable Lesion SURGERY

Lesion non-resectableAggressive medical

therapy


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General Measures Antibiotic therapy:

Choice of antibiotic depends on the isolates Most exacerbations are caused by the bacteria

colonizing the diseased airway Empirical therapy :

Co-amoxyclav/ Ceftriaxone + ciprofloxacin (particularly in those with

pseudomonal colonization). Airway Clearing:

Very important tool, but underused promote bronchial hygiene improve breathing efficiency promote physical reconditioning


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Jatin presented with fever, chest pain, expectoration: 6 weeks

Did not respond to broad spectrum antibiotics

He had mild clubbing, bronchial breathing right infrascapular region and crepitations all over right side of chest


What are the diagnostic possibilities?


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Causes of lung abscess Most frequently a complication of bacterial

pneumonia especially those due to Staphylococcus aureus, Klebsiella pneumonia and Pseudomonas.

May develop in sequestration of lung tissue or in association with foreign bodies, bronchial cysts or stenosis.

Staphylococcal lungs abscess are often multiple, while those complicating aspiration are solitary.

May rupture into the pleural space leading to Pyopnuemothrax


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Antibiotics Used

Lung abscess (from community) S. aureus K. pneumoniae P. aeruginosa

Cefotaxime/ ceftriaxone and Cloxacillin


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CONCLUSIONS Viral infections and non infectious causes of

cough do not need antibiotic therapy. Few situations for empiric use of antibiotics

and Unwarranted use does not prevent a

subsequent secondary infection in most situations.

First line antibiotics are still effective and drugs of choice

Newer 3rd - 4 th generation Antibiotics should be reserved for few non responders.

All non responders are not due to a resistant bug. Other causes are as important.


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CREDITS RTI GEM Varinder Singh (Team Leader)

Mahesh Babu R J Chinappa

G Ghosh S K Kabra

Indu Khosla Raju P Khubchandani

Tanu Singhal(alphabetic order)


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Sponsored Through Educational Grant by

Cipla


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THANK YOU FOR YOUR KIND ATTENTION

IAP RTI GEM

Health & Medicine

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