Respiratory Topics for DCH

teaching

Outline

• IMCI approach

• Community acquired pneumonia

• Pleural effusion

• Approach to chronic cough

• Approach to stridor

• Approach to persistent/recurrent wheeze

• HIV-associated chronic lung disease

Baby P

• 8m old presents with fever and cough for 5days

• Previously well and thriving

• Mom HIV- and breastfeeding

• Exam: Temp 38, coryza and red throat

normal breathing

PLAN: ????

Baby P

• Returns 3 days later not better. Now poor feeding and vomiting.

• Exam T38.7; pink in RA ; RR 70 bpm; no air trapping; coarse crackles and BBr anterior on right

• DIFF DIAGNOSIS??

• INVESTIGATIONS?

• AETIOLOGY?

• MANAGEMENT?

CAP prevention

• General

– Good nutrition

– Breastfeeding

– PMTCT

– Micronutrient supplementation (Vit A in

measles, Zinc) NB in malnourish4ed and

HIV+

– Reduce ETS and biomass duel exposure

– Routine vaccination (BCG, Dip, Polio,

Pertussis, HiB, Pneumococcal, measles)

Specific vaccines

• Pneumococcal conjugate vaccine (PCV): 13-Valent vaccine now on EPI– 20-37% reduction radiological pneumonia in HIV –

children, and 13% in HIV+

– 2-3X greater reduction in clinical pneumonia (all

cause)

– 85% reduction in invasive Pneumoc disease (HIV-)

and 65% in HIV+

– Other indirect benefits:

• Decrease viral-assoc pneumonia by 32%

• Decrease penicillin resist IPD by 67%

• Decrease IPD in overall population and elderly

• Decrease child mortality in poor areas without healthcare

Polysaccharide 23-valent vaccine• Indicated for HIV- children > 2yrs at risk of IPD (XX??)

• Preceded 1 month prior by PCV in children 2-9 yrs

• C/I in HIV + adults (? Children)

Influenza vaccine

Prophylaxis

• Cotrimoxazole for PCP

– HIV exp: 6 weeks until PCR –

– HIV+: Until > 1 year (regardless of HAART)

Lifelong if no HAART

Until CD4% > 25% 6 months apart if on

HAART

• INH all TB exposed/infected < 5ys without disease

• RSV monoclonal antibody (Palizumab)

Baby P cont...

• After 2nd day Amoxicillin,

still febrile, coughing and

tachypnoeic. Sats 92%

RA; dullness Rt persists

with softer BS post on Rt

• WHAT ARE POSSIBLE

REASONS FOR

FAILURE TO IMPROVE?

• WHAT

INVESTIGATIONS?

• WHAT

INTERVENTIONS?

Pleural effusions

TB EFFUSIONS VS EMPYEMA

Management

TB effusions Empyema

ABC’s

Drain if large and symptomatic

Standard TB Rx

No role for steroids unless

complicated (pain, fever...)

Notify

Collect sputum for culture

Screen for HIV

ABC’s

Always needs drainage unless very

small. Drain in until afebrile 24 hrs and

no drainage

Antibiotics to cover Strep pneum and

Staph aureus; IV initially, change to

oral if afebrile > 48hrs.

Consider routine fibrinolytics or with

loculated empyema

Refer for surgery if unwell and febrile

despite antibiotics and drainage

Chronic cough

• Consider significant if > 3 weeks duration

• Pattern of cough NB ie persistent vs recurrent with

asymptomatic intervals

• Pointers on Hx and exam– Duration and pattern e.g. nocturnal only or disappears at night

– Creche attendance

– Dry vs Wet

– Acute onset and hx of choking

– TB contact? Household smokers or other environmental exposures

– HIV exposure/infection

– Vomiting and regurgitation

– Exercise induced cough and other signs of atopy or asthma eg wheeze

– Associated with URTI’s or not

– Look for signs of chronic lung disease ie FTT, halitosis clubbing, chest

deformity, persistent air trapping, wheeze or crackles

Investigate chronic cough only when...

• If probably post infective (viral/pertussis), watch ,

reassure and see. No role for OTC medications

• If suspicious of PAR or asthma, trial and Rx and then

review ie topical or inhaled steroids, antihistamines

• Suspected FB aspiration or associated “noisy

breathing”– refer bronchoscopy

• Investigate for TB if suspected

• HIV test

• Consider other investigations when indicated eg CXR,

sputum MCS, lung function and BDR in children> 5,

sweat test, aspiration studies, immune workup etc

Approach to stridor

• CROUP • Stridor= noisy breathing during

inspiration arising from the

laryngeal and sometimes proximal

tracheal obstruction

• Stertor= noisy breathing arising

from nasopharyngeal obstruction

• Noise level does NOT correlate

with severity of airway obstruction

• Distinguish stridor since

birth/chronic vs. Acute onset or

recurrent

Causes of stridor

Acute onset/recurrent Persistent/chronic

Infants Croup

Diptheria

Candida

CMV (HIV+)

Subglottic stenosis

congenital or post-

intubation

GORD

Congenital abnormalities

eg laryngeal, skeletal

abn =eg Pierre Robin

GORD

Vocal cord paralysis

Laryngeal papillomas

Subglottic stenosis

Subglottic haemangioma

Vascular ring

Toddlers/children Croup

GOR

Foreign body

above

CROUPSeverity Insp obstruction Exp obstruction Palpable pulsus

paradoxus

Grade 1 +

Grade 2 + Passive

Grade 3 + Active +

Grade 4 Grade 3 plus

marked retraction,

apathy and

cyanosis

• Grade 1and 2: supportive care; Adrenaline inhalations; avoid crying; systemic steroids

• Grade 3: O2; continuous adrenaline nebs; systemic steroids (pred 2mg/kg; IV dexa 0.6mg/kg); sedation if needed

• Grade 4: urgent intubation

• Antimicrobials: antibiotics (tracheitis); Acyclovir (herpes); fluconazole (candida); Gancyclovir (CMV)

Baby W

• 14 m old presents with

cough, runny nose and

wheeze

• 4th admission for similar

symptoms

• Growing well, HIV-, fully

immunised, well most of

the time

• Exam: T 37.7, Sats 88%

RA, RR 60;bilateral air

trapping; loud wheeze

and diffuse crackles

• WHAT OTHER HX

NEEDED?

• WHAT IS THE DIFF

DIAGNOSIS?

• WHAT

INVESTIGATIONS?

• WHAT IS YOUR

MANAGEMENT?

CXR Baby W

Recurrent and persistent wheeze

Recurrent Persistent

< 1 year Bronchiolitis

Aspiration episodes

Aspiration syndrome eg

GORD, laryngeal

incompetence

CF; cilliary dyskinesia

Post infectious PAO eg

BO from RSV,adenovirus

BPD

Tracheobronchial

obstruction eg vascular

ring, TB nodes

> 1 year Bronchiolitis

Episodic viral wheezeMulti-trigger wheeze

Asthma

Above PLUS

Uncontrolled asthma

Foreign body aspiration

TB nodes

Differential diagnosis of HIV+ children with respiratory symptoms

• Upper respiratory tract disorders

• Allergic conditions eg asthma, allergic rhinitis

• Lymphoproliferative disorders eg LIP

• Lower respiratory tract infections– common infections eg bacteria and viruses

– Opportunistic infections eg PCP or cytomegalovirus or fungal infections

– Tuberculosis

• Diseases of pleura eg pleural effusion

• Malignancy eg Kaposi Sarcoma or Lymphoma

• non-respiratory causes eg cardiac disease ; Aspiration syndromes or GORD; metabolic acidosis from diarrhoeal disease

Mechanisms of HIV-related pulmonary disease

Immunodeficiency

•Mucosal/local immunity

•Cell mediated immunity (CD4)

•Humoral immunity: Active

Passive

•Ineffective immunisations

•malnutrition

Opportunistic infections

eg PCP

Increased frequency and

severity of other common

infections eg bacterial

pneumonia and PTB

Lymphoproliferativedisorders

Immune dysregulation

Direct HIV infection and replication

in lung tissue causes immune –

mediated cytokine injury and

dysregulation

Lymphocytic interstitial pneumonitis (LIP)

Reactive airways disease

Hypersensitivities

Differential diagnosis of pulmonary conditions in HIV+ childrenInt J Tuberc Lung Dis 2006;10:1331-36

Illness CauseClinical features

Age range

Diagnosis

Tuberculosis M. Tuberculosis

Subacute onset, persistent and unremitting cough, weight loss, fever

All ages

Sputum microscopy/culture, TST, Hx of contact, CXR

Bacterial pneumonia

S. pneumoniae, H Influenzae, S. aureus, Gram neg organisms

Rapid onset, high fever, elevated WCC

All ages Blood culture

Viral pneumonia

RSV, Adenovirus, Influenza, CMV,EBV

Air trapping and wheezing infants>

older childrenClinical

LIPImmune response to EBV

Slow onset, cough, associated with gen LAD, parotitis, clubbing

Older children

Clinical

PCPPneumocystis jirovecii

Acute severe hypoxic pneumonia infants

Clinical, sputum for PCP IF

BronchiectasisRecurrent RTIs, LIP, TB

Slow onset, chronic productive cough, halitosis, clubbing

Older children

CXR

Differentiating between PCP and bacterial pneumoniaInt J Tuberc Lung Dis 2005;9:592-602

Feature PJPBacterial pneumonia

Age Infants (2-6 months) All ages

Fever Low grade or absent Usually febrile > 38.5C

Hypoxia Marked and persists > 48 hours

Variable and improves with treatment

Auscultation Clear or diffuse findings

Focal or diffuse findings

Response to usual antibiotics

Poor Good

CXR abnormalities Diffuse interstitial or hyperinflation

Usually focal

Outcome Very poor Usually satisfactory

Chronic/persistent lung disease in HIV –infected children

• CLD remains common as children continue to present late without ART, have repeated RTIs, Tuberculosis and LIP

• Differential diagnosis of children presenting with persistent (> 2 months) respiratory symptoms (cough, dyspnoea, wheezing, bronchial breathing or CXR abnormalities:– Lymphoid interstitial pneumonitis (LIP)

– Chronic HIV-associated lung disease / Bronchiectasis

– Tuberculosis (primary, complicated primary, miliary)

– Non-tuberculous mycobacteria eg M. avium; M .bovis

– Malignancy: Kaposi sarcoma, lymphoma

– Non-specific interstitial pneumonitis

– Aspiration syndromes eg GORD

Lymphoid interstitial pneumonitis

• A chronic lymphocytic infiltrative disease thought

to result from an dysregulated immune response

with HIV/Ebstein-Barr virus interaction

• Typical features are peribronchiolar lymphoid

follicles and lymphocytic infiltration of the alveolar

spaces

• Associated with a better outcome and seen more

in older children (> 2 years)

• Most common form of CLD in HIV+ children

LIP: clinical presentation

• Chronic cough (> 2 months) and variable

dyspnoea and even hypoxia (sats < 90%)

• May be asymptomatic in early stages

• Usually present with secondary respiratory

infections and LIP an ‘incidental finding’

• Co-infections and co-morbidity eg

bronchiectasis, pneumonia and TB are

common and may vary the presentation

LIP: Clinical features

• Lymphocytic proliferation in lymphoreticular organs > generalised lymphadenopathy, tonsilar and adenoidal hypertrophy, hepatosplenomegaly

• Auscultion findings vary

• Repeated respiratory infections eventually > bronchiectasis > cor pulmonale

• As HIV advances and CD4 count diminishes, less lymphoproliferation may result in disappearance of these features including pulmonary infiltrates

Digital clubbing Chest deformity Parotid enlargement

LIP: Diagnosis

• Compatible symptoms and

signs PLUS

• Exclusion of other

diseases/infections eg TB

PLUS

• Typical xray findings

– Bilateral reticulo-nodular infiltrates of varying size and distribution

– ± hilar LAD

– ± focal lung disease

LIP

Miliary TB*Lung biopsy not indicated anymore

Clinical and radiological features differentiating TB from LIP

Clinical features PTB Miliary TB LIP

Respiratory symptoms Common Uncommon Common

Persistent fever Common Common Common

wasting Common marked Variable

Generalised LAD Uncommon Uncommon Common

Parotid enlargement Rare Rare Common

clubbing Uncommon Rare Common

Marked HSM Uncommon Uncommon Common

CXR features

Focal parenchymal Common Uncommon Uncommon

Diffuse micronodular Negative Common Uncommon

Diffuse reticular Negative Negative Common

lymphadenopathy Common Uncommon Common

LIP: treatment

• Exclude and treat secondary bacterial infections

• Exclude TB co-infection

• Bronchodilators may be helpful

• Oral corticosteriods if significant symptoms or hypoxia

• Antiretroviral therapy is most effective treatment and most LIP will disappear with ART

Chronic HIV-associated lung disease (CHALD)

• Bronchiectasis/CHALD is the final common end-point of persistent/recurrent lung disease eg TB, recurrent pneumonia, LIP

• Present with chronic history of productive cough

• Clinical findings: wasting, digital clubbing, halitosis, focal abnormalities on auscultation, usually coarse crackles

• CXR: focal abnormalities; ±air trapping, atelectasis, consolidation, bronchial dilatation

CHALD: Treatment

• Treat intercurrent bacterial infections with appropriate antibiotics.

• Exclude TB co-infection

• Regular chest physiotherapy to promote drainage

• Bronchodilators if bronchodilator responsive

• Vaccinations against Step. Pneumoniae and Influenzaadvisable

• Regular cardiac function evaluation

• Antiretroviral Therapy is most effective to prevent further respiratory infections and improvement in general well-being

• Timeous ART should hopefully in future prevent and reduce the incidence and severity of CHALD