Video Cases in Pediatrics Ran Goldman, MD BC Children s Hospital University of British Columbia @Dr_R_Goldman
Bronchiolitis Viral infection of the lower respiratory tract characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, increased mucus production, and bronchospasm
Almost all children will have RSV by the age of 2 3% hospitalized Rarely mortality Peak age 2-5 months Rare in 1 st month of life
Respiratory syncytial virus (RSV) 70% Metapneumovirus 10-20% Parainfluenza Influenza 10-20%
Incubation period Upper respiratory infection Worsening lower airway disease Full recovery 2-8 days 1-3 days 3-5 days 2-8 weeks
Supportive care Airway clearance Hydration Oxygen Bronchodilators?
Humidified oxygen Nasal suctioning Monitor (apnea, hypoxemia, failure) Reduce temperature Rehydration
Multiple studies of bronchodilators o Albuterol (Beta 2 adrenergic effects) o Racemic epinephrine (Beta 2 adrenergic effects Alpha adrenergic effects -? Vasoconstriction) o Anticholinergics No evidence for benefit in bronchiolitis
Hartling et al. Cochrane Review 2004
Odds of improvement Hartling et al. Cochrane Review 2004
Hospitalization Hartling et al. Cochrane Review 2004
Hypertonic Saline conflicting results. May be a role in children who are hospitalized with bronchiolitis for more than 3 days,
Steroids A Cochrane review (2013) + Systematic Review in Annals EM (2014) No benefit of oral steroids with respect to length of stay and admission rates for children with Bronchiolitis
Apnea and RSV 20% of hospitalized infants Risk factors for apnea : oage < 2-3 months, Prematurity Recurrence rate 50% Mortality < 2% Infants discharged with oxygen were fine after a few days at home Levine et al. 2004, Halstead et al. 2012
RSV and Asthma? 40-50% of hospitalized bronchiolitics will wheeze again Increased risk if > 12 months, atopy, eosinophilia Martinez FD, Godfrey S, 2003 Reijonen 1997 Ehlenfield 2000
Croup Onset often abrupt Barking Cough and Hoarse Voice Inspiratory Stridor Respiratory Distress Fever-usually low grade Non-toxic Symptoms worse at night, last 48 hours
Severity Assessment Determines who needs Epinephrine Stridor at rest AND one of the following: Sternal Retractions Tachypnea Agitation/restless/tired appearing Difficulty talking or feeding
Keep Calm and Quiet Croup Racemic Epinephrine inhalation solution Steroids (0.6mg/kg PO Dexamethasone, Max dose 16 mg) Heliox: 70/30 Helium/Oxygen Mix (?) Intubate for Respiratory Failure
Ancillary Studies No role for routing labs or x-rays No role for viral testing CBG if concern about respiratory failure
Discharge Home Observe 2-4 Hours following racemic epinephrine No stridor at rest Parents able to return if symptoms worsen
Refusal to Walk Infections septic arthritis, osteomyelitis, discitis, myositis Inflammatory transient synovitis Trauma abuse, fractures, soft tissue injury Bone related slipped epiphysis, a-sceptic necrosis (legg-calve-perthes), vaso-occlusive crisis, tumors. Neurologic weakness (GBS), ataxia, Psychogenic - conversion
Questions to ask Onset of symptoms? Trauma? Febrile illness/viral illness? Nausea/vertigo/posterior fossa symptoms? Progressive? Ascending?
Myositis Commonly experienced myalgias ---- > rhabdomyolysis with renal failure
Myositis Mild to moderate myalgias occur during the prodrome Mild muscle tenderness Ankles are held in a plantar flexed position Resist attempts to dorsiflex the ankle
Guillain-Barre syndrome 2-4 weeks after a viral illness Distal paresthesia and ascending paralysis Symmetric weakness with NO decreased deep tendon reflexes Jain. CMAJ. 2009
Habitual Cough small, harsh tinny type sound Becomes persistent for weeks/months Severe frequency Lack of other symptoms. No cough asleep
Dart RC et al. Ann Emerg Med 2009;53(4):411-7
Honey In paired comparisons, honey was significantly superior to no-treatment or honey-flavoured dextromethorphan for: Cough frequency and severity Bothersome nature of the cough Child sleep quality Parent sleep quality Paul IM et al. Arch Pediatr Adolesc Med 2007;161(12): 1140-6
Video Cases in Pediatrics Ran Goldman, MD BC Children s Hospital University of British Columbia @Dr_R_Goldman