Dr.Sivaramakrishnan PICU KKCTH
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
Afebrile/sick looking Severe respiratory distress (RR=80/min) Bilateral wheeze/scr/icr/ssr INVESTIGATIONS Mild anaemia / leucocytosis / negative CRP Normal RFT
IN ER CXRay showed bilateral increased BVM With haziness in left lower zone
Child continuously nebulised IV hydrocort/mgso4/sc terbutaline given Wheeze persisted Distress worsened shifted to PICU
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
CX-RAY Child worsened further
ICD placed
Repeat X-Ray: No improvement PH-6.8 /PCO2-199 /PO2-51 /HCO3-34 /SPO2-54%
FOREIGN BODY versus recalcitrant asthma BRONCHOSCOPY PLANNED
BINGO BRONCHOSCOPY FOREIGN BODY in rt. Main bronchus CULPRIT-thoor dal Edema of bronchial mucosa seen & purulent secretions suctioned out
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
Post extubation
Post ICU stay
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
Irritable/sick looking Tachypnoeic (RR-54/min) Febrile/haemodynamically stable B/L extensive wheeze
continuosly nebulised IV hydrocort/mgso4/sc terbutaline given INVESTIGATIONS N counts with mild anemia/positive CRP Normal liver enzymes & RFT
CX-RAY IN ER Due to worsening distress shifted to PICU
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
Following day Marginal improvement Cont to be tachypneic Cxray rpt
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
BRONCHIAL CAST
Child improved dramatically Nebulisations decreased N acetyl cysteine nebulisations added Steroids continued Wheezing settled Child shifted out next day for further care
POST BRONCHOSCOPY
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.
Child discharged on inhaled bronchodilators Reviewed 1 week later No symptoms of recurrence Doing well
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
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
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
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
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
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.
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
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
FOLLOW UP Recurrence very common No strict pattern of recurrence No preventive therapy Bronchoscopy immediately if child comes with recurrence PROGNOSIS good
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
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
THANK YOU