PEDIA Case 3.1. Acute Bronchiolitis
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Transcript of PEDIA Case 3.1. Acute Bronchiolitis
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Pediatrics 2: Ward Case
#4
Nicer, Stefi Diane
Olarte, Carla Mae
Palatino, John Paul
Pangan, Kimberly Anne
Pangilinan, Mary JunevePascua, Krinzel Mae
Perez, William
Pescante, Nina Carmela
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GENERAL DATA
Informant: Mother of patient
Reliability: 90%
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GENERAL DATA
• C.M.
• 1 month and 3 weeks old
• Female
•Birthdate: August. 30, 2014
• Birthplace: lying-in clinic Dasmarinas, Cavite
• 1st admission at OMMC
• Date of admission: October 8, 2014
• Time of admission: 11:00 pm
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CHIEF COMPLAINT
DIFFICULTY OFBREATHING
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HISTORY OF PRESENT ILLNESS
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2 WEEKS PTA
• Patient had colds with a clear nasal discharge.
• Medical consult was done in the lying-in clinic
– phenylephrine HCl, chlorphenamine maleate
(Disudrin)
– 0.3 mL every 6 hours with afforded relief in 2 days
• No other associated symptoms like fever,
cough, chills, change in appetite were note.
• Patient was apparently well until 3 days PTA
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3 DAYS PTA
• Patient had productive cough of yellowishsputum accompanied by colds
• Patient was irritable and cannot be easily
pacified.• Weight loss noted as described by mother.
• Same medication, frequency and dosage wastaken
• No other accompanying symptoms. No consultwas done.
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DAY OF ADMISSION
• Patient’s condition persisted and mother noticed
difficulty of breathing described as effortful and
• Patient was referred to OMMC, hence the
admission and slower than usual.
• Presence of grunting, subcostal retractions and
alar flaring were noted.
• Patient was irritable and has a weak cry
• Patient was brought to OMMC, hence admission.
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REVIEW OF SYSTEMS
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REVIEW OF SYSTEMS
Skin (+) skin rashes (-) color change (-) changes in nails
(-) lumps
Head (-) trauma
Eyes (-) excessive lacrimation (-)redness
Ears (-) discharge
Nose (-) epistaxis
Mouth and Throat (-) bleeding gums
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REVIEW OF SYSTEMS
Gastrointestinal (+)posttussive vomiting (-)diarrhea (-)constipation
(-)hematochezia (-)melena
Genitourinary (-) gross hematuria (-) dyscharge (-)genital swelling
Hematologic (-) easy bruising
Endocrine (-) excessive sweating
Nervous/
behavioral
(-) paralysis (-) convulsion
Musculoskeletal (-) stiffness
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PERSONAL HISTORY
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A. Gestational History
• 27 years old with OB index of G3P2 (2-0-0-2)
when the patient was being conceived.
• no complications throughout the course of
pregnancy.
• In good health, and denied intake of any drugs
during the time of conception.
• Duration of gestation: 9 months (37 weeks).
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• OB index: G3P3 (3003)
Birthdate Place Manner of
Delivery
Attendant Sex Status
1 08/9/08 Lying in
clinic in
Dasma
NSD Doctor M No
reported
diseases
2 10/14/10 Lying in
clinic in
Dasma
NSD Doctor M No
reported
diseases
3 08/30/14 Lying in
clinic in
Dasma
NSD Doctor F Curently in
the hospital
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B. Birth History
• Term
• via NSD
•
in a lying-in clinic in Damarinas City, Cavite• attended by a physician.
• Birth weight at birth: 3.2 kg
• born as a well-baby.
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C. Neonatal History
• no complications upon delivery
• good cry
•
spontaneous respiration• no cyanosis, pallor, nor jaundice.
• no convulsions, hemorrhage, congenital
abnormalities, nor birth injury.
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D. Feeding History
• breastfed most of the time
• given formula milk ~once a week, whenever
the mother has to go somewhere leaving the
patient behind.
• 9x/day
• 12 minutes in each breast/about 24 minutes
per session.
• Ascorbic acid and multivitamins (Tiki-Tiki Star)
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Immunization History
• No allergies to food, medications, pollen noranimals
• Hasn’t had any other illnesses nor injuries
Past Illnesses
•
Hepatitis B – 1 dose at birth
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Family HistoryFamily Member Age Occupation Diseases
Father 28 Container van driver None
Mother 28 Housewife None
Siblings 6 None None
4 None None
•
No medical problems for blood-relatives such astuberculosis, diabetes, cancer, epilepsy, rheumaticfever, allergy, asthma, hypertension, heart disease,stroke, kidney disease, blood disorder nor mentaldisorder.
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Socioeconomic History
• Living conditions
– Currently lives in an apartment with one
bedroom, occupied by 5 other family members
• Economic circumstances
– Two members of the family, the patient’s father
and uncle have jobs and their incomes are the
family’s source of funds
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Environmental History
• Has exposure to cigarette smoke from her
father and uncle
• No other pollutants identified
• Garbage collected periodically however they
resort to burning of garbage materials when
there’s none, about once weekly
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PHYSICAL EXAMINATION
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General Survey
• Quality of cry: slightly weak cry (whimpering)
• Reaction to parent stimulation: Cries briefly thenstops
•
State of variation: if asleep and stimulated, thenwakes up quickly
• Color: Pink
• Hydration: Skin Normal and and eyes, mouth
moist; CRT
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Vital Signs
• T: 38.3 C, axillary
• HR: 120 bpm , regular
•
RR: 50 bpm, regular• Acute Ilness Observational Scale: 8
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Anthropometric Data
• Weight: 6.5 kg
• Length: 62 cm
•
Head circumference: 39cm• Chest circumference: 36cm
• Abdominal circumference: 37cm
• BMI: 15.61
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Skin
• (-) pallor, jaundice, flushing, cyanosis
• pinkish
• fair skin tone
• smooth, no breaks
• (+) erythematous papulovesicular rash (diaperarea)
• moist in skin folds
• normal skin turgor
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Head
• no trauma
• normocephalic
• Scalp: no infestations, clean
• Hair: fine, normal distribution
• (-) swelling, hematoma, abscess
• Symmetrical facial expression
• Fontanels: – AF: slightly depressed, pulsatile, open
– PF: closed
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Eyes
• Eyelids: symmetrical
• No periorbital edema
•
pinkish conjuctiva• anicteric scelra
• equal pupil size
•equal accomodation and convergence
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Ears
• normoset external pinnae
• no discharge
•
(-) tenderness• (+) gross hearing
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Nose
• symmetrical nasolabial folds
• midline septum
• pinkish mucosa
• no discharge
• both nostrils are patent
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Mouth and Pharynx
• midline tongue
• lips: pinkish, cutest
• gums pinkish
• no teeth
• uvula midline
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Neck
• midline
• (-) palpable thyroid, lymph nodes
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Chest and Lungs
• AP diameter = transverse diameter
• Movements with respiration: mostly
abdominal
• (-) chest retractions
• symmetrical chest expansion
•
vesicular breath sounds: all lung fields• (-) adventitious breath sounds
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Cardiovascular
• Inspection: No observed precordial bulging.
No visible pulsations in the chest
• Palpation: PMI measures approximate 2cm on
left 4th intercostals space MCL, no thrills.
• Percussion: Not done
• Auscultation: No abnormal murmurs or heart
sounds (S3 and S4) noted. No pericardial
friction rub
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Abdomen
• Inspection: Abdomen is globular and symmetric.No visible superficial veins, scars, or localized areaof bulging, masses and other lesions.
• Auscultation: With audible normoactive bowel
movement sounds (7/min) gurgling in quality. Nobruits auscultated.
• Palpation: Soft and non-tender abdomen. Nonoted involuntary rigidity or muscle guarding. Liver
edge is not palpable over the right costal margin.Non palpable spleen.
• Percussion: Not assessed
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Genitalia
• Grossly female
• Size, location of labia, clitorius, meatus and
vaginal opening are normal for age
• Tanner stage 1
• No discharge or pseudomenses
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Peripheral vascular & Extremities
• No tremors, no twitching, no involuntarymovements
• No clubbing, edema, swelling and deformities
noted• No tenderness noted
• Capillary refill < 2 seconds
• Pink nail beds
• Radial, and dorsalis pedis pulses 2+ for both leftand right extremities
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NEUROLOGICAL EXAM
C i l N
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Cranial NervesCRANIAL
NERVES
FINDINGS
I N/A
II N/A
III N/A
IV N/A
V N/A VI Eyes are symmetrical. Pupillary size equal, equally reactive to
light, direct and consensual pupillary reflex, accommodation and
converegence
VII N/A
VIII Gross hearing is intact
IX N/A
X N/A
XI N/A
XII Tongue is at the midline. No atrophy, grooving or fascuculations
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Neurological Exam
• Motor Testing
o Examination of the gait and posture, musclebulk, muscle tone and strength and
coordination is not applicable in theexamination of the patient
• Cerebellar Function (N/A)
• Sensory Testing (N/A)
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Reflexes
Reflexes Score
Deep Tendon Reflex
Patellar reflex 2+
Primitive reflexes Moro reflex
Rooting reflex
Grasp (Palmar and Plantar) reflex Babinski
Tonic neck reflex
+
+
+ +
+
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Reflexes
• Deep Tendon Reflex
– Patellar Reflex 2+
• Primitive Reflexes (all positive)
– Moro
– Rooting
– Palmar and Plantar Grasp
– Tonic Neck
– Babinski
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SALIENT FEATURES
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• < 2 months old
• Previously healthy
• Parental smoking
• History of mild upper respiratory infection manifested by colds with clearrhinorrhea.
• No fever
• Cough
• Signs of respiratory distress:
Dyspnea
Irritable Effortful breathing
Weak cry
Grunting
Alar flaring
Subcostal Retractions
• No tachypnea
• No crackles
• No wheezing
• No other systemic symptoms
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APPROACH TO DIAGNOSIS
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COUGH
w/ signs ofrespiratory
distress
No othersystemic
symptoms
Respiratory
system OtherSystemsAcute (3weeks)
Viral
PneumoniaAcute
Bronchiolitis
Bronchialasthma
ObstructiveSymptoms
RestrictiveSymptoms
i l i
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Viral PneumoniaRule in Rule Out
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Bronchial AsthmaRule in Rule Out
•
Epidemiology: Most common chronic diseaseof Childhood and 33% before 2 y.o.
• Parental smoking
• History of mild upper respiratory infection
manifested by colds with clear rhinorrhea
• No fever
•Cough
• Dyspnea
• Irritable
• Effortful breathing
• Weak cry
• Grunting
• Alar flaring• Subcostal Retractions
• No other systemic sxs
•
No family history of Asthma• No Intermittent dry coughing
• No expiratory wheezing
RULED OUT
A B hi li i
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Acute BronchiolitisRule in Rule Out
1 month old The infant first develops a mild upper
respiratory tract infection with clear
rhinorrhea
Temperature can range from subnormal to
markedly elevated Respiratory distress ensues, with paroxysmal
wheezy cough, dyspnea, and irritability.
The child does not usually have other
systemic complaints, such as diarrhea or
vomiting
Apnea may be more prominent than
wheezing early in the course of the disease,
particularly with very young infants (
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ACUTE BRONCHIOLITIS
Working Diagnosis
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DIAGNOSTIC WORK-UP
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Diagnostic Work-Up
• Diagnosis is basically made clinical and based
upon history and physical examination
(Kliegman et al., 2010).
• However, because concurrent bacterial
infection is highly unlikely, confirmation of
viral bronchiolitis may obviate the need for a
sepsis evaluation in a febrile infant (Kliegmanet al., 2010).
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CBC and Differentials
• To look for coexisting bacterial infection
• WBC and RBC differential counts usually normal (without the lymphopenia seen with other viral
illnesses) (Kliegman et al., 2010) – WBC count (8000-15000/ul) and may be left-shifted as
a result of stress (DeNicola, 2014)
– However, it is noted that mong infants with a febrile
illness, WBC values are highly variable. No WBC countthreshold has good discriminatory value for the presence of bacterial infection (DeNicola, 2014)
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Chest Radiography
• Useful in excluding unexpected congenital
anomalies or other conditions (e.g. lobar
pneumonia, congestive heart failure)
• AP and lateral views
• May reveal hyperinflated lungs with patchy
atelectasis
– difficult to distinguish from early bacterial
pneumonia (Nelson, 2003)
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Pulse Oximetry
• To determine severity of illness but does not ruleout other diagnoses (e.g. asthma, pneumonia)
• Transcutaneous oxygen saturation
–
good indicator of the severity of bronchiolitis – correlates best with tachypnea; however, correlates
poorly with wheezing and retractions (DeNicola, 2014)
• Persistent resting oxygen saturations
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Viral Testing
• To determine the viral pathogen to help guide
treatment
• Rapid immunofluorescence, ELISA, PCR
• Viral culture
– Standard for a definitve diagnosis
• RSV most commonly isolated organism (26-
95%) (DeNicola, 2014)
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MANAGEMENTManagement for patients with Acute
Bronchiolitis is directed toward symptomaticrelief and and maintenance of hydration and
oxygenation since there is no definitivetreatment for specific viruses.
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INITIAL MANAGEMENT
• Patient should be made as comfortable aspossible.
• Administer saline nose drops and perform
nasal and oral suctioning if needed.• Careful monitor for presence of apnea.
• Pay attention to temperature regulation in
small infants• Adequate hydration should be maintained and
careful fluid monitoring.
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CRITERIA FOR ADMISSION• Persistent resting oxygen saturation below 92% in room air before
beta-agonist trial• Markedly elevated respiratory rate (>70-80 breaths/min)
• Dyspnea and intercostal retractions, indicating respiratory distress
• Desaturation in 40% oxygen (3-4 L/min oxygen), cyanosis
• Chronic lung disease, especially if the patient is on supplemental
oxygen• Congenital heart disease, especially if associated with cyanosis or
pulmonary hypertension
• Prematurity
• Age younger than 3 months, when severe disease is most common
• Inability to maintain oral hydration in patients younger than 6months
• Difficulty in feeding as a consequence of respiratory distress
• Parent unable to care for child at home
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CRITERIA FOR ADMISSION IN ICU
• Worsening hypoxemia or hypercapnia
• Worsening respiratory distress
• Continuing requirement for more than 40%
oxygen• Apnea
• Acidosis
•
Extrapulmonary symptoms• Worsening mental status
• Unclear etiology of symptoms
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OXYGEN SUPPLEMENTATION
• Oxygen therapy should be started when:
– oxygen saturations are persistently below 92%
– significant respiratory distress.
• Maximum oxygenation via nasal prongs is 2.5
L/min
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MAINTENANCE OF HYDRATION
• Oral feeds can be continued if the child is able to
take greater than 50% of usual feeds without
significantly increased work of breathing.
• Feeding 2-3 times hourly with decreased volumemay be helpful.
• Encourage to continue breastfeeding
•Mothers should also maintain their oral fluids anddietary intake to prevent reduction in the supply
of breast milk.
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PHARMACOLOGIC THERAPY
• BRONCHODILATORS
– Produce modest short-term improvement in
clinical features
– Ipatropium bromide appears to be effective as anadjunct therapy.
– Not recommended routinely
–
Not recommended for infants
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PHARMACOLOGIC THERAPY
• ANTIINFLAMMATORY AGENTS
– Corticosteroids whether parenteral, oral or
inhaled have been used for bronchiolitis despite
conflicting and often negative studies. – Corticosteroids are not recommended in
previously healthy infants with RSV (Kliegman,
2007)
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PHARMACOLOGIC THERAPY
• ANTIVIRAL AND ANTIBIOTICS
– Ribavirin, an antiviral agent administered by aerosol, has
been used for infants with congenital heart disease or
chronic lung disease.
– There is no convincing evidence of a positive impact on
clinically important outcomes such as mortality and
duration of hospitalization.
– Antibiotics have no value unless there is secondary
bacterial pneumonia.
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Prognosis
Acute Bronchiolitis
• At highest risk for further respiratory
compromise in the first 48-72 hours after
onset of cough and dyspnea
• Child may be desperately ill with:
– Air hunger
– Apnea
– Respiratory acidosis
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Prognosis
• Case fatality:
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Prognosis
• After critical period of symptoms,
symptoms can persist
–
Median duration of symptoms inambulatory patients: ~12 days
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Complications
• Subsequent airway reactive disease
– Recurrent wheezing
– asthma
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Prevention
• Pooled hyperimmune RSV intravenousimmunoglobulin
• Palivizumab
– An intramuscular monoclonal antibody to the RSVF protein
– For infants
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References
• Kliegman, R. 2007. Nelson textbook of
pediatrics.18th ed. USA: Saunders Elsevier. p.
1474-1479.
• Mejias, A., M.W. Hall and O. Ramilo. 2013.Ummune monitoring of children with
respiratory syncytial virus infection. Retrieved
on 26 October, 2014 from www.patient.Co.uk/doctor/bronchiolitis-pro
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References
• Kliegman RM et al. 2010 Nelson Textbook of
Pediatrics. 19ed. Elsevier, Inc.
• DeNicola, LC. 2014. Bronchiolitis Workup.
Medscape. Retrieved on 26 Oct, 2014 athttp://emedicine.medscape.com/article/9619
63-workup#showall