Respiratory Topics for DCH teaching

Transcription

1 Respiratory Topics for DCH teaching

2 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

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5 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 PLAN:???? normal breathing

6 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? Baby P

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11 General Good nutrition Breastfeeding PMTCT CAP prevention 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)

12 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

13 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

14 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)

15 Baby P cont... After 2 nd 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?

16 Pleural effusions

17 TB EFFUSIONS VS EMPYEMA

18 Management TB effusions 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 Empyema 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

19 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

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21 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

22 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

23 Causes of stridor Infants Toddlers/children Acute onset/recurrent Croup Diptheria Candida CMV (HIV+) Subglottic stenosis congenital or postintubation GORD Croup GOR Foreign body Persistent/chronic Congenital abnormalities eg laryngeal, skeletal abn =eg Pierre Robin GORD Vocal cord paralysis Laryngeal papillomas Subglottic stenosis Subglottic haemangioma Vascular ring above

24 CROUP Severity 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)

25 Baby W 14 m old presents with cough, runny nose and wheeze 4 th 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?

26 CXR Baby W

27 Recurrent and persistent wheeze Recurrent < 1 year Bronchiolitis Aspiration episodes Persistent 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 wheeze Multi-trigger wheeze Asthma Above PLUS Uncontrolled asthma Foreign body aspiration TB nodes

28 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

29 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 Lymphoproliferative disorders 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

30 Differential diagnosis of pulmonary conditions in HIV+ children Int J Tuberc Lung Dis 2006;10: Illness Cause Clinical 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 children Clinical LIP Immune response to EBV Slow onset, cough, associated with gen LAD, parotitis, clubbing Older children Clinical PCP Pneumocystis jirovecii Acute severe hypoxic pneumonia infants Clinical, sputum for PCP IF Bronchiectasis Recurrent RTIs, LIP, TB Slow onset, chronic productive cough, halitosis, clubbing Older children CXR

31 Differentiating between PCP and bacterial pneumonia Int J Tuberc Lung Dis 2005;9: Feature PJP Bacterial pneumonia Age Infants (2-6 months) All ages Fever Low grade or absent Usually febrile > 38.5C Hypoxia Auscultation Response to usual antibiotics Marked and persists > 48 hours Clear or diffuse findings Poor CXR abnormalities Diffuse interstitial or hyperinflation Variable and improves with treatment Focal or diffuse findings Good Usually focal Outcome Very poor Usually satisfactory

32 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

33 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

34 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

35 LIP: Clinical features Digital clubbing Chest deformity Parotid enlargement 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

36 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 *Lung biopsy not indicated anymore Miliary TB

37 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

38 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

39 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

40 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 Influenza advisable Regular cardiac function evaluation Antiretroviral Therapy is most effective to prevent further respiratory infections and improvement in general wellbeing Timeous ART should hopefully in future prevent and reduce the incidence and severity of CHALD