Dr.Sivaramakrishnan PICU KKCTH

Transcription

1 Dr.Sivaramakrishnan PICU KKCTH

2 CASE 1 11/2 year old female child Known wheezer on intermittent bronchodilators Admitted with h/o cough for 2 days Increased work of breathing for 1 day

3 Afebrile/sick looking Severe respiratory distress (RR=80/min) Bilateral wheeze/scr/icr/ssr INVESTIGATIONS Mild anaemia / leucocytosis / negative CRP Normal RFT

4 IN ER CXRay showed bilateral increased BVM With haziness in left lower zone

5 Child continuously nebulised IV hydrocort/mgso4/sc terbutaline given Wheeze persisted Distress worsened shifted to PICU

6 Nebulization's continued Child worsened further - intubated ABG PH-7.16/PCO2-86/PO2-179/HCO3-30/SPO2-99% Terbutaline & MgSO4 infusions started Did not improve despite various ventilator manipulations

7 CX-RAY Child worsened further

8 ICD placed

9 Repeat X-Ray: No improvement PH-6.8 /PCO2-199 /PO2-51 /HCO3-34 /SPO2-54%

10 FOREIGN BODY versus recalcitrant asthma BRONCHOSCOPY PLANNED

11 BINGO BRONCHOSCOPY FOREIGN BODY in rt. Main bronchus CULPRIT-thoor dal Edema of bronchial mucosa seen & purulent secretions suctioned out

12 Dramatic improvement ABG-PH-7.4/PO2-84/PCO2-48/HCO3-29/SPO2-97% Infusions gradually tapered off Nebulisations frequency decreased Extubated on 5 th day of ICU stay Unremarkable post extubation ICU stay

13 Post extubation

14 Post ICU stay

15 2 yr old male child Known wheezer since early infancy Admitted with h/o cough 4 days Increased work of breathing & fever 2 days No H/S/O FB aspiration On intermittent nebulisations

16 Irritable/sick looking Tachypnoeic (RR-54/min) Febrile/haemodynamically stable B/L extensive wheeze

17 continuosly nebulised IV hydrocort/mgso4/sc terbutaline given INVESTIGATIONS N counts with mild anemia/positive CRP Normal liver enzymes & RFT

18 CX-RAY IN ER Due to worsening distress shifted to PICU

19 Child had persistent wheezing O/E: sick,very irritable, tachypnoeic ICR/SCR/SSR Decreased breath sounds in LT B/L crackles & wheeze Nebulisations continued Hydrocortisone continued

20 Following day Marginal improvement Cont to be tachypneic Cxray rpt

21 BRONCHOSCOPY LT bronchial system:both lingula & UL bronchi are filled with mucus cast suggesting PLASTIC BRONCHITIS RT bronchial system normal Thorough bronchial lavage done Cast removed by repeated saline wash

22 BRONCHIAL CAST

23 Child improved dramatically Nebulisations decreased N acetyl cysteine nebulisations added Steroids continued Wheezing settled Child shifted out next day for further care

24 POST BRONCHOSCOPY

25 In HDU had resp distress again, urgent bronchoscopy done again revealed a cast similar to the first one - removed intoto and thorough lavage given. Improved and shifted to ward.

26 Child discharged on inhaled bronchodilators Reviewed 1 week later No symptoms of recurrence Doing well

27 Formation of obstructive bronchial plugs or casts of thick, tenacious mucus associated with involvement of one or more lobes or even associated entire lung may collapse. FIBRINOUS/PSEUDOMEMBRANOUS/HOFFMAN S BRONCHIAL CROUP First described as early as 1902

28 AGE affects all ages Youngest reported being 3 wks PRECIPITATING FACTORS commonly associated with hyper reactive airway disease (asthma, pneumonia), cystic fibrosis, bronchiectasis, chronic bronchitis, inhalation of aeroallergens, CHD, bronchopulmonary aspergillosis or may sometimes be IDIOPATHIC

29 MODERATE INFLAMMATORY CHANGES in bronchial wall most constantly associated. May include congestion and edema of bronchial wall or sometimes haemorrage and infiltration by polymorphonuclear leukocytes, eosinophils or lymphocytes

30 Signs of infection (fever, cough, dyspnea etc) h/s/o underlying disease often present wheeze localised or bilateral Decreased air entry in collapsed side Resp distress Adults sometimes cough out cast Mimics FB/status asthmaticus

31 CX-RAY one or more areas of collapse No predilection to any part of lung Recurrent attacks may lead to fibrosis & bronchiectasis BRONCHOSCOPY diagnostic and therapeutic

32 Cylindrical / adherent to bronchial wall Pale grayish or greenish white Peculiarly tough & viscid with smooth surface 2 types of cast INFLAMMATORY : made up of fibrin & esonophil infiltrates. Usually in underlying bronchial disease ACELLULAR : mainly mucin with little fibrin, no inflammatory infiltrates. Usually in CHD SEER ET AL.

33 MUCUS PLUG Small plugs Causes segmental collapse Not very tight Can be expectorated PLASTIC BRONCHITIS Large plugs Collapse of entire lobe/lung Tightly adherent Retained rather than expectorated

34 Beta agonists Steroids beneficial but yet uncertain NAC (breaks disulfide bonds in mucin thus lowering their viscosity) Aerosolised urokinase / heparin have been tried Aerosolised tpa (fibrin enhanced conversion of plasminogen to plasmin which initiates local fibrinolysis. Used in casts with high fibrin content. No definitive data, so can be tried in refractory cases) Chest physiotherapy BRONCHOSCOPY

35 FOLLOW UP Recurrence very common No strict pattern of recurrence No preventive therapy Bronchoscopy immediately if child comes with recurrence PROGNOSIS good

36 ALL THAT WHEEZES IS NOT ASTHMA High index of suspicion to any child presenting with acute respiratory distress with wheeze refractory to conventional medical therapy with unusual radiographic picture consider BRONCH SCOPY

37 sleigh johnson & E.G sita lumsden THORAX 1960 J.Y park,a.a elshemi EUR.RESPIR J,1996 John m.costeldo,david steinhom,pediatrics 2002 D.Vijayasekaran,N.G.gowrishankar IP 2004

38 THANK YOU