iap rti gem
TRANSCRIPT
RTI – GEMRESPIRATORY TRACT INFECTIONS
– GROUP EDUCATION MODULE
Based on IAP CONSENSUS PROTOCOL FOR THE MANAGEMENT OF
RESPIRATORY TRACT INFECTIONS IN CHILDREN
Indian Academy of PediatricsPresidential Action Plan 2006
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The process A group of conveners
and a mix of “experts” Sharing of
responsibility Wider representation
Review of literature on identified topics
Draft guidelines- meeting and discussions
RTI Facts – Booklet in ACT and FACT format
Group Education Meetings - RTI-GEMs
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NATIONAL TASK FORCE for
RATIONAL ANTIBIOTIC THERAPY IN CHILDHOOD RESPIRATORY TRACT
INFECTIONS LED BY
NITIN SHAH (Chairperson) ROHIT AGARWAL (Convenor) VARINDER SINGH (Convenor) VIJAY YEWALE (Co-convenor) DEEPAK UGRA (Co-ordinator)
Members: (alphabetic order)
A Balachandran Mahesh Babu J Chinappa Krishan Chugh Bela Doctor S K Kabra
Indu Khosla Raju P Khubchandani
G Ghosh G R Sethi Rasik Shah
Meenu Singh Tanu Singhal
Advisers : YK Amdekar Raju Shah Tapan GhoshNTFRTI
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Road Map Today
Basic understanding of the issue Starting with a syndromic approach
Child with a Fever, Cough, with or without Nasal/ Ear discharge
Child with Fever, Cough and Noisy breathing
Child with Fever, Cough, and Rapid & Difficult Breathing
Understanding RTI and rational
therapy
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Why infections of Respiratory Tract?
About 3 million children die every year before they reach the age of 5 due to RTIs.
Of these, 1.9 million deaths occur in India.
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What is rational antibiotic treatment?
Antibiotic prescription should ideally comprise of the following phases:
Perception of need - is an antibiotic necessary?
Choice of antibiotic – which is the most appropriate antibiotic?
Choice of regimen : What dose, route, frequency and duration are needed?
Monitoring efficacy : is the antibiotic effective?
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What is the current practice? Five commonest reasons for antimicrobial drug
use among children with respiratory conditions: nonspecific upper respiratory tract infections, pharyngitis, otitis media, Sinusitis, and bronchitis
Most of these antimicrobials are often
unwarranted.
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The first error Erroneous trust in their ability to treat all
infections (read fever) with antibiotic prescription. Many fevers are not due to infections Majority of infections seen in general practice
are of viral origin. Antibiotics often prescribed in the belief
that this will prevent secondary bacterial infections No evidence except where chemoprophylaxis
is advocated.
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Errors galore Using the “best” cover with the latest, potent,
broad spectrum antibiotic. But it may not be the best and also not the safest too.
Injectables are used often than needed The duration of use is often not regulated. Often upgrade or change the antibiotics for a
patient who continues to have fever despite antibiotic use. Causes are many like incorrect diagnosis, incorrect
dose and/or route of administration or incorrect choice of drug, phlebitis, and not always due to antibiotic resistance.
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Does it matter?
Drug Resistance is a function of exposure to drug
It is Genetic in origin Prevent Access to Site
Decrease Influx Increase Efflux
Inactivate Drug Change Site of Action
http://www.sciam.com/1998/0398issue/0398levybox2.html
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Perhaps it matters more than we think it does
Versatile Genetic Engineers Equilitarian and Social Horizontal Transmission of
Resistance Genes among Species
http://www.sciam.com/1998/0398issue/0398levybox3.html Gene Transfer in the Environment. Levy & Miller, 1989
Child with Fever, Cough and Nasal or
Ear discharge
Pharyngotonsillitis Sinusitis Otitis Media
Watch this sign- The ball is in your court!
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Supriyo falls ill
Supriyo, 1 yr male, Brought with history of acute
onset cough with rhinorrhoea.
What more would you like to know? What would you expect on
examination?
The ball is in your court!
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acute onset, red eyes, rhinorrhea, diarrhea, No exanthema, hoarseness, cough +++ Similar cases in family Throat mild congestion
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Clinically diagnosed : Seasonal viral pharyngotonsillitis
CBC / Throat Culture : not needed.
How will you Manage? General & Symptomatic Therapy Antibiotics : Not needed.
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Therapy Rest, oral fluids and salt water gargling- mainly
supportive. Avoidance of irritants (e.g. smoke) Analgesics and antipyretics - Paracetamol DOC Normal saline nasal drops may help, particularly in <2yrs,
other nasal decongestants sparingly for short term First generation antihistamines may relieve rhinorrhea by
25 – 30%. Cough suppressants? Brandy/ soup/ other special Diet / Zinc/ Herbal products:
No confirmed role.
Takes 5-7 days to resolve, so do explain
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6 year old Arjun was brought to your clinic with 2 day history of high spiking fever and mild cough
What more will you ask?
Case History
The ball is in your court!
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Acute onset, Has no red eyes, or rhinorrhea or diarrhea, No exanthema, Difficulty in swallowing, not even able to take
liquids easily Cough mild, No history of similar cases in the family Arjun prefers to sleep most of the day.
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Examination Arjun looks ill, RR 28, HR 110, Sats, perfusion and B.P
normal. Rt tonsil showed a purulent
discharge with inflammation of both tonsils.
Bilateral tender cervical LN++,
Ear and Nose – Normal, Other system examination –
normal
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“What does Arjun have?” asks the mother. “I had been to a nearby doctor in the morning
and have been prescribed antibiotics, should I continue
it”, she adds?”
The ball is in your court!
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Diagnosis: Tonsillitis !!!
Your resident doctor then asks you, “how did you decide to use antibiotics here?” The ball is in your
court!
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Supriyo and Arjun
Supriyo Acute onset, Red
eyes, rhinorrhea, cough, diarrhea, Generalized maculo- papular rashes.
Pharyngeal exudates and cervical lymphadenopathy less common.
Most probably viral
Arjun Explosive onset, throat
pain, rapid progression, very little cough/cold.
Pharyngeal congestion more, thick exudates, ulcers and vesicles, purulent patchy tonsils with tender LN++, Toxicity +++
Most probably bacterial
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Viral vs Bacterial
Signs with good predictive values Presence of watery nasal discharge Absence of pharyngeal erythema Absence of tender lymphadenopathy Suggest Viral PTL More of these, better the predictability
No single sign is definitive
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Diagnosis of viral is mainly clinical. Blood count, ESR and C- reactive protein level
can help but have a low predictive value.
Throat culture Gold standard for diagnosing streptococcal
pharyngitis. However cannot diff between carriers and case. Negative throat culture result has a very high
negative predictive value for GAS pharyngitis. Major drawback – lag time of 18-48 hours
Pharyngo-tonsillitis
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Rapid Antigen Detection tests (RADT) have good sensitivity and specificity, but are expensive and not easily available.
Streptococcal antibody testing (ASO) etc has no role in the diagnosis of acute streptococcal pharyngitis
Is there a simpler way?
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Your resident then asks you “Why and which antibiotics should one choose ?”
GABHS is self limiting disease recovering within 3-4 days. The goals of
pharmacotherapy are to reduce morbidity and to prevent complications. Complications can be prevented even if the antibiotics are started as late as by the 9th day of illness.
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In children with no Penicillin allergy
Antibiotic (route) (days) Children (< 30kg) Children ( > 30kg)
Penicillin V (Oral) (10d) 250 mg BID 500 mg BID
Amoxycillin (Oral) (10d) 40mg/kg/day 250 mg TID
Benzathine penicillin G (IM) (single dose)
6 lakh Units 1.2 Million Units.
In children with Penicillin allergy (Non type 1)
Antibiotic ( route ) ( days) Children ( < 27 kg)
Erythromycin ethylsuccinate (oral) (10ds) 40-50 mg/kg/day TID
Azithromycin (oral ) ( 5days) 12 mg/kg OD
I generation Cephalosporin (oral) (10ds) Cephalexin / Cefaclor* in usual doses.
II Line: Clindamycin (oral) (10days) 10-20 mg / kg.
*early second generation
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2 months later, Arjun is back with fever, cough and coryza. See his throat
Doctor considers him to have viral pharyngitis.
DO YOU AGREE?
HERPANGINA
The ball is in your court!
Pharyngeal Erythema but not bacterial
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Some more non-bacterial inflmn
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“But doctor” asks the mother “This is the 3rd episode of
tonsillitis that Arjun has had in the past 2 years, and one of my family physicians has advised
tonsillectomy for him.
What is your opinion?
The ball is in your court!
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Guidelines for considering tonsillectomy
1. 7 or more episodes of tonsillitis in 1 yr.2. 5 or more episodes per year over a 2
year period.3. Enlarged tonsils that create significant
upper airway obstruction.4. An abscess in the tonsils.
Large tonsils like this if not causing any obstruction need
no intervention
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Management Protocol
Examine eye / ear / nose / body
Conjunctivitis / CoryzaHoarseness / Cough
Purulent / Patches /Toxic / Tender L.Nodes
• Viral ?• Symptomatics (3-4d)
• Bacterial • Antibiotics before
/ after Culture
Responds No Resp.
ResponseFollow up
Culture/RADT
-- ve
+ ve
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Arjun returns
Arjun, our 6 yr old, returns after 10 days, He has fever & headache for past 3 days.
O/E Purulent Nasal discharge, Slight Periorbital edema with tenderness on percussion on maxillary and frontal sinuses
Diagnosis ?????
The ball is in your court!
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Arjun has developed Sinusitis
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When does one suspect sinusitis?
Usually Clinical
Prolonged, upper respiratory signs/symptoms >10-14 days
Severe upper respiratory signs/symptoms (Fever > 1020F, Facial swelling and pain)
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Classification of Sinusitis Acute Infection<30 days;
Persistent:>14/<30 days; Severe: Temp>102 °F, Purulent
discharge, Sick child.
Subacute:- 30-90 days
Recurrent:-<30 days ;Relapse after 10 days
Chronic :->90 days.
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Development of sinuses
Maxillary and Ethmoid sinuses
10th wk POG At birth
Sphenoid sinuses
3yrs 8yrs
Frontal sinuses
7-8 years Early teens
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Predisposing factors
Viral URI Allergic rhinitis and
Nasal Polyps
Nasal Foreign Body Adenoidal
Hypertrophy Nasogastric tube
Cleft Palate GERD
Mucociliary disorders PCD CF Kartageners Syndrome
Immunodeficiency states
Dental infections
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Common Pathogens Acute and Subacute Sinusitis
Strept. Pneumoniae Non typeable H influenzae Moraxella catarrhalis Strept pyogenes (beta hem)
Chronic Sinusitis Bacterial Pathogens not well defined Polymicrobial infection common Alpha hemolytic Strept., Staph aureus,
CONS, Non typeable H influenzae, Moraxella catarrhalis & Anaerobic Bacteria
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What are the diagnostic facilities for sinusitis?
Clinical History Examination Radiology Microbiology
Diagnosis of Sinusitis is essentially clinical.
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X-Rays Abnormal X-Rays-
complete opacification, mucosal thickening of at least 4 mm, or an air-fluid level.
In children below 6 yrs history predicted abnormal sinuses in 88%
In children older than 6yrs history predicted abnormal sinuses in 70%
Technical difficulties to achieve positioning.
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Guidelines for Diagnosis Radiological
X-rays therefore not needed in most. Clinical correlation is good. X rays recommended if:
Recurrent Complications Unclear diagnosis
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X-Rays Waters view
Maxillary and Frontal sinuses
Caldwells view- Frontal sinuses seen
well Ethmoid & sphenoid
superimposed.
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Other views: Open mouth view-Sphenoid sinuses Lateral View Sphenoid Sinus.
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Management Medical Antibiotics Main stay :
Amoxycillin (40 mg/kg/d) Cefuroxime Co amoxy clav- can be second line if
initial choice was Amoxycillin Select Any of these based on cost and safety
If severe disease or failure to first line drugs: Parenteral Ceftriaxone / Cefotaxime then
may switch to oral Cefopodoxime
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Management Medical Treat for 10-14 days or 1 week beyond
symptom resolution, which ever is later
In case of persistent non response – imaging and sinus aspiration should be done.
Adjuvant Therapies : Limited Data, Not recommended.
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Azhar 15 month boy
Azhar, a 15 month otherwise healthy boy had rhinorrhea, cough and fever of 1020F for two days.
On day 5, he became fussy and woke up crying multiple times at night
WHAT COULD BE WRONG?HOW DOES ONE EVALUATE THIS CHILD ?
The ball is in your court!
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CLINICAL EXAMINATION
ENT EVALUATION OTOSCOPE
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OTOSCOPY FINDINGS AZHAR HAD WAX IN THE EAR.
EAR DRUM COULD NOT BE VISUALISED
WHAT COULD YOU DO?
ATTEMPT TO REMOVE WAX [only if soft] Soft – Curette Hard- Solvent
EMPIRIC TREATMENT In acute phase wax removal can be painful so
empiric therapy may be used
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THE RIGHT TYMPANIC MEMBRANE WAS RED AND HAD WHITE FLUID BEHIND THE UMBO
THE FOLLOWING DAY HE HAD SLIGHT REDNESS OF THE LEFT TYMPANIC MEMBRANE AND NO FLUID
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AZHAR HAS ACUTE OTITIS MEDIA RIGHT EAR
Erythema Fluid Impaired mobility Acute symptoms
MANAGEMENT ?
The ball is in your court!
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Management AOM – Under 2 Yrs
Analgesia Paracetamol in adequate doses as good as
Ibuprofen Decongestants no role Antibiotics in divided doses for 10 days
Choices first line Amoxycillin/ Co-amoxyclav Second line
Second generation cephalosporins e.g. Cefaclor, cefuroxime.
Co amoxyclav – if not used earlier
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Follow up: Reviewed at 72 hrs
If improving- Continue the antibiotic for ten days
If patient deteriorates Consider changing the antibiotic
Choices are i.m. Ceftriaxone Or third generation oral
Cephalosporins like Cefopodoxime, Cefdinir AND NOT Cefixime as has poor
action against St pneumoniae
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10th DAY OTOSCOPY
Azhar has improved completely-- general follow up
The patient has no signs of inflammation but dullness and bulging remain in both ears
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DIAGNOSIS MEE
Middle ear effusion is a common complication following AOM
Seen in younger age groups Management?
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NO ACTIVE TREATMENT Needs review every two weeks Usually resolves by 12 weeks Tympanometry is helpful in follow-up for
resolution
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MONICA 7 Yr Old
Monica, a 7 yr old child complains of mild fever, sore throat and discomfort in the left ear for a few hours
She has just started swimming lessons On examination she has mild throat
congestion, rhinitis and an erythematous bulging left tympanic membrane
DIAGNOSIS AND MANAGEMENT ?
The ball is in your court!
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Management of AOM in >2 yr old
Analgesics Mainstay of treatment
Decongestants have a questionable role Antibiotics
No urgency to start antibiotics unlike a <2 yr old baby
Wait and watch for 48-72 hrs Start antibiotics only if deterioration Drug of choice Amoxycillin 40mg/kg/day in
two divided doses for 7 days
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Co-amoxyclav
Mild to moderate
< 2yrs
Amoxycillin
> 2yrs
Wait for 48 hrs If worse, Amox
Red drum
Observe
resolve
•Remove wax•Consider
tympanometry•Empiric treatment•ENT consultation
Indeterminate
Red & bulging
Severe disease*
* Severe disease - Explosive onset, Severe Otalgia, Toxicity and High grade fever 1020F+
Background ARI, ear tugging, fever, irritability, otalgia
Otoscopy
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AZHAR returns
Azhar was lost to follow up comes back to you at 2.5 years of age. The mother says he speaks little while his sister at same age used to speak a lot more. Whatever little he speaks has been unclear and gibberish. He has had 4 episodes of
ear infections in the last six months.He goes to a day care centre and is bottle fed
WHAT IS WRONG WITH HIM?
The ball is in your court!
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EVALUATION
Deviated septum Snoring Bilateral dull tympanic membranes with
limited mobility Diagnosis? Management?
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Chronic Middle Ear Effusion
No active signs of inflammation Investigation of choice –Tympanometry Careful follow up If no resolution at 12 weeks
consider grommet /adenoidectomy Removal of risk factors
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Ambica, a 16 Month Old
This malnourished child is brought with chronic purulent ear discharge of three months duration
Investigations and Management?
The ball is in your court!
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Chronic Suppurative Otitis Media
Nutrition Combination of oral antibiotics (as
before) and local antibiotics (quinolones) for at least two weeks
Early referral to ENT service
Child with Fever, Cough and Noisy
Breathing
Croup Diphtheria Pertussis
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Harshad – a child with fever, cough and noisy breathing
2 year old Harshad, presents with 1 day history of mild grade fever and running
nose. His mother also says that his voice has changed and that his cough this time has a peculiar sound which
she has not heard before.
What are the possibilities? What other information one needs?
The ball is in your court!
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Harshad - Analyzed
Characteristics: Acute onset Fever, running nose and cough – infective
etiology – likely to be upper airway Changed cough character – likely to be
involving larynx Hence an acute upper airway infection –
laryngitis +
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Other information required: Is the child playful? Is the child feeding well? History of similar complaints in the past?
His mother says that Harshad is quite playful and has been eating well. He does not seem to be disturbed by his loud and almost barking cough. He has not had any similar episodes in past.
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O/E: Harshad is a active playful 2 year old, well nourished. His temp is 990F in axilla.
Ant rhinoscopy reveals rhinitis. His ears and throat are normal.
Harshad does have a barking loud cough, and a high pitched inspiratory noise, particularly after coughing and crying. But is absent during rest.
What could the diagnosis be?
The ball is in your court!
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Acute viral croup
How should Harshad’s illness be graded?
The ball is in your court!
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Grading severity of croup
Mild Moderate SevereGeneralAppearance
Happy, Feeds well, Interested in surroundings
Fussy but inter- active. Comforted by parents.
Restless, agitated. Altered sensorium.
Stridor Stridor on coughing and crying. No stridor at rest.
Stridor at rest worsening with agitation
Stridor at rest worsening with agitation
RespiratoryDistress
No distress Tachypnoea, Tachycardia and chest retractions
Marked Tachycardia, with chest retractions
Oxygenation > 92% in room air
>92% in room air
<92% in room air. Cyanosis.
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Harshad has Mild Croup.
How should one treat Harshad?
The ball is in your court!
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Croup - TreatmentMild Moderate Severe
SteroidsOral/Nebulized/IM
? Yes Yes
NebulizedAdrenaline
No No (May be given if deterioration noted during observation)
Repeated doses may be required.
Oxygen No No As required to keep SaO2 >92%
ANTIBIOTICS NO ROLE
NO ROLE NO ROLE
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Harshad has mild croup
Hence Harshad requires symptomatic treatment
Mother may also be advised to give Humidified air inhalation / bathroom steaming
Few authorities may use a single oral dose of Prednisolone / Dexamethasone to decrease the parental stress as well as the risk of return to medical care.
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Parental advice
Parents to be informed that croup generally gets more severe at nights.
To look out for increasing severity manifested by increasing stridor, increasing breathing difficulty and the child getting increasingly agitated with refusal of feeds.
To come back to medical assistance if severity increases.
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Harshad’s mother rings you up in the middle of the night because his breathing severity has increased
and she is bringing him to the emergency.
O/E Harshad now has a audible stridor at rest, He is crying and restless but is consolable by parents. His HR 120, RR 26, Sats 92% in room
air. He has minimal intercostals retractions, and has good air entry bilaterally.
Do we need to run tests on him? How should he be treated now?
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Investigating Croup
Investigations not required in typical croup. Croup is a clinical diagnosis. In a child with airway obstruction, neck
radiographs or blood tests cause anxiety which may precipitate further distress and obstruction.
X-ray AP view of the soft tissues of neck if done – reveals a tapered narrowing (steeple sign)
of the subglottic trachea instead of the normal shouldered appearance.
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X-ray AP View of neck showing a classical narrowed steeple like tracheal air column at larynx
with a dilate hypo pharynx as seen in Croup
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Harshad now has moderate croup
Observation for upto 4 hours. Steroids:
If not given before, a dose of oral/nebulized/IM steroid has to be given.
If it is > 12h since previous dose, repeat dose of Nebulised steroid can be given.
Nebulised Adrenaline: Used if symptoms are increasing, and repeated if
clinically indicated (0.5ml/kg of 1:1000 dilution to maximum of 5ml). Routinely available adrenaline is as effective as racemic adrenaline.
If asymptomatic at the end of 4 hrs, he can be discharged.
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Steroid and Adrenaline Dose
Steroids Repeated doses of 2 mg nebulised budesonide 12h x
48hrs Oral and intramuscular dexamethasone is equally
efficacious Oral corticosteroids are preferred for their ease.
Doses: Dexamethasone 0.15–0.3 mg/kg Prednisolone is 1–2 mg/kg.
Adrenaline Adrenaline is used in severe cases and those poorly
responsive to steroids. Need for repeated doses should alert for the probable
need for intubation/ PICU care.
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“Why steroids to my child?” Asks Harshad’s mother.
What advice should one send this child home with?
The ball is in your court!
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Steroids in Croup The use of steroids has been associated
with A reduced average length of stay in the
emergency department. A significant decrease in the number of
adrenaline nebulizations required. A reduced need for endotracheal intubation. If required, the duration of intubation is
decreased. Current evidence more strong for its
efficacy in moderate to severe croup.
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At the end of 2 hours, Harshad was clearly unwell. He is now non
consolable. His saturations are 84 – 86% in room air and requires 2 lts of
Oxygen by nasal cannula.
How should one treat Harshad?
The ball is in your court!
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Harshad has developed signs of severe croup Continue Oxygen as required. Admit Continue Nebulised adrenaline as frequently
as needed clinically If adrenaline is required more than 2 hourly, then
he has to be shifted to a place with intensive care facilities.
Steroids to be continued. If airway obstructions/ work of breathing is
worsening, then one has to consider intubation and ventilation. Preferably use a tube half size smaller then optimal.
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Croup – Key points Croup is essentially a viral illness. No investigations are required in a child with
typical croup Most children with croup develop a mild
illness and do not require any medical assistance.
Steroids are extremely useful and indicated in a child with moderate and severe croup.
Steroids can be given orally, IM or Nebulised and all routes are equipotent.
Adrenaline nebulization is reserved for children with severe croup.
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Lakhan 2 year old has persistent cough with some noise
Lakhan has been coughing for past 2 weeks or so. He had low grade fever of initial few days.
Gets severe bouts of coughing, more often when the mother is cooking on her kerosene stove.
Few of the times, he becomes totally out of breath and makes a loud sound, which the mother describes as if its coming from a dog.
What more information does one need?
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Lakhan has Whooping Cough or Pertussis.
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When should one suspect pertussis?
Any individual (child/ adolescence) with Prolonged (2 weeks or more) paroxysmal
cough With or without whoop/ post tussive
vomiting Irrespective of immunization
Respiratory illness with complications like conjunctival hemorrhages, fractures, rectal prolapse or encephalopathy,
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Paroxysmal cough is an essential criteria Even partially immune individuals retain this
Typical paroxysm : A series of rapid, forced expirations (usually 5-10), followed
by gasping inhalation, leading to the typical whoop. Cyanosis, bulging eyes, protrusion of the tongue, salivation,
lacrimation and distension of the neck veins occurs Post-tussive vomiting is common. Can occur several times per hour during both day and night triggered by yawning, sneezing or physical exertion.
Whoop and post tussive vomiting component of the paroxysm may not be found in the partially immune- therefore not essential for diagnosis
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How to confirm the diagnosis ? CBC
Absolute lymphocyte count > 10,000/ l ALC above age specific mean has 70% sensitivity Normal count does not exclude pertussis Neonates may have much higher counts
CXR Not sensitive or specific Role of cultures - not of practical importance Serology and PCR Not recommended
routinely Diagnosis usually clinical aided by CBC
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Treatment Antibiotics
• Reduce transmissibility• May reduce symptoms if given in 1st week• Limited role as usually diagnosed later
Gentle suction for removal of secretions Avoidance of cough provoking factors Humidified oxygen and assisted ventilation if required
Dose & Duration Status
Erythromycin 40-50 mg/kg/day q 6 hrly X 14 days
Side effectsDuration/ adherenceNot < 1 month
Clarithromycin 15 mg/kg/day Q 12 hrly X 7 days
ExpensiveDrug interactionNot < 1 month
Azithromycin < 6 mths:10 mg/kg/day X 5 d> 6 mths: 10 mg/kg on day 1 and 5 mg/kg day 2-5
CheapNo drug interactionsCan be given < 1 mth
Cotrimoxazole 8 mg/kg of TMPQ 12 hrly X 14 days
Intolerant/CI of macrolides
Azithromycin is DOC considering all factors
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Treatment- Supportive
Not of any benefit Antihistaminics Steroids Salbutamol Pertussis immunoglobulin
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Un-immunised child, has difficult noisy breathing x 2d
Mother reports mild moderate grade fever and sania is very lethargic and dull for 1 day.
Mother also feels that her neck is swollen. O/e
Temperature 1000F Laboured noisy breathing Diffuse swelling of her neck. Throat examination : a greyish white membrane over
the pharyngo-tonsillar area and beyond. The membrane bleeds on touch and is difficult to remove
Sania, 4 year old female child
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What is Sania likely sick from?
Sania probably has Diphtheria
http://www.idph.state.il.us/about/immunepics/diphtheria2.htm
The ball is in your court!
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Suspecting diphtheria : Sore throat with membrane in tonsillopharyngeal
area Fever, hoarseness, barking cough, stridor,
membrane over pharynx and larynx Sero-sanguinous nasal discharge, crusts and a
white membrane on septum Late Presentations : may not be any visible
membrane Palatal or bulbar palsy Myocarditis with prior sore throat Acute polyneuropathy with or without prior sore throat.
May occur even in previously immunized
Confirming diphtheria Smear and culture of the membrane or scraping
below the membrane Stain with Neisser or Albert stain
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How will you treat Sania?
Hospitalization in infectious disease facility Droplet isolation till three consecutive daily
cultures are negative Start treatment without waiting for
microbiologic culture confirmation Components of therapy
Diphtheria antitoxin (DAT), most crucial Antibiotics Supportive care Management of complications
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Treatment - DAT
Always administer test dose
If allergic desensitize Full dose given IV at one
time, diluted in NS (1:20), rate of 1 ml/minute
Limited availability at ID hospitals
Serum sickness in 10% patients
Type Total dose in units
Nasal 10,000- 20,000
Laryngeal/ Pharyngeal
20,000- 40,000
Tonsillar 15,000-25,000
Combined types/ delayed diagnosis
40,000-60,000
Severe disease* 80,000 –100,000
Carrier/ Contact Not required
*extensive disease/ more than 3 days duration/ neck edema/tachycardia/ collapse/ breathlessness
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Treatment continued
Antibiotics (Penicillin G/ Procaine penicillin/ Erythromycin for 14 days)
Strict bed rest for 2- 3 weeks Adequate nutrition and hydration Steroids not recommended Carnitine 100 mg/kg/day BD for 4 doses
may help prevent myocarditis Complete immunization on recovery
Child with Fever, Cough, and Rapid &
Difficult Breathing
BronchiolitisCommunity Acquired PneumoniaNosocomial PneumoniaRecurrent PneumoniaEmpyemaBronchiectasis
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Luv AND Kush are 3 month old twins who were born at 34 week of gestation. Luv was oxygen dependent for 4 days after birth and has been doing well since then. Kush required ventilation for 6 days after birth and was off oxygen after Day 16 of age, and has been well since. No other neonatal problems.
They were brought to the clinic with 4 day history of fever, cold and cough. Kush also had history of refusal of feeds since the past 8 hours.
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Luv O/E: RR 60/min, HR 130/min, Pink, well
perfused, Saturations 96% in room air, Active, interested in surroundings. Minimal sub coastal in drawing, Good air entry bilaterally, occasional rhonchi++. Other systems – normal.
“What does my child have?” asks the mother
The ball is in your court!
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Features: Young, well looking infant Tachypnea++ Tachycardia++ Saturating well Bilateral scattered wheezeMost likely diagnosis: Bronchiolitis
How severe is it? Asks the mother
The ball is in your court!
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Grading bronchiolitisMILD MODERATE SEVERE
FeedingAbility
Normal Ability to feed
Appear short of breath During feeding
May be reluctant or unable to feed
RespiratoryDistress
Little or no respiratory
distress
Moderate distress with some chest wall retractions and nasal flaring.
Brief self limiting apnoeas
Severe distress with marked chest wall retractions, nasal flaring and grunting.
Can have frequent and prolonged apnoeas
SaturationsSaturations
>92%
Saturations <92%, correctable with O2
Saturations <92%, may or may not be
correctable with O2
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“Luv has mild bronchiolitis”, I explained to the mother.
“What medications do I need to give him?”, she asked.
The ball is in your court!
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Bronchiolitis - Treatment
Mild Moderate Severe No
treatment required.
Reassure mother.
To bring the baby back if distress increases
Admit Humidified oxygen to
maintain sats > 92% IV fluids Observe for deterioration If the child deteriorates
treat as severe
Admit – ICU care O2 to maintain sats >92% IV fluids Cardio respiratory
monitoring ABG/CXR Assess need for
ventilatory support / ICU care
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Kush O/E: Febrile 101º F , RR 80/min, HR
150/min, sats 88% in room air, crying incessantly, dry paroxysmal cough, supra sternal and sub coastal in drawing++, hyper inflated chest, bilateral rhonchi and scattered creps++, Liver and spleen just palpable below coastal margins. Other systems normal.
What are the diagnostic possibilities?
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Most likely diagnosis – bronchiolitis Differential diagnosis:
Pneumonia GERD with aspiration Foreign body Congenital heart disease Congenital anomalies like vascular ring
How should Kush’s severity be graded?
The ball is in your court!
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Grading bronchiolitis
Mild Moderate Severe
No treatment required.
Reassure mother.
To bring the baby back if distress increases
Admit Humidified oxygen to
maintain sats > 92% IV fluids Observe for deterioration If the child deteriorates
treat as severe
Admit – ICU care O2 to maintain sats >92% IV fluids Cardio respiratory
monitoring ABG/CXR Assess need for ventilatory
support / ICU care
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“Why my babies?” asked the mother. “Why are both of them affected? Is their resistance poor? Is it because they were preterm babies?”
What are the children at high risk of disease and increased
severity?
The ball is in your court!
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Bronchiolitis – Risk factorsAn increased risk severity and of bronchiolitis related hospitalization seen in following:
Infants in day care Exposure to passive smoke Crowding in the household Infants younger than 2 – 3 months Premature birth < 34 – 37 weeks Congenital heart disease Chronic Lung disease like CF, Recurrent aspiration,
BPD, Congenital malformations etc Immunodeficiency Hypoxia
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“Luv is fine and I can handle him at home, but Kush is not feeding. How do I handle him? Do I
treat him differently? I do not think I can manage the two separately one at home and
other here”.
How should Kush be managed? – Discuss What are the indications for admitting a
child with bronchiolitis?
The ball is in your court!
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Bronchiolitis - Treatment
Mild Moderate Severe
No treatmentrequired. Reassuremother.To bring thebaby back if distressincreases
AdmitHumidified oxygen tomaintain sats > 92%IV fluidsObserve fordeterioration If the child deteriorates
Admit – ICU careO2 to maintain sats>92%IV fluidsCardio respiratorymonitoringABG/CXRAsses need forventilatory support / ICU
care
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Bronchiolitis – Indications for hospitalization
Infants younger than 3 months Oxygen saturation < 92% RR > 70/min ILL appearing child Infants with one or more risk factors
mentioned before are likely to have a severe course and merit admission.
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So, you explain to the mother that Kush needs admission for observation and treatment and she agrees.
Your resident doctor who is now going to take care of the admission and in-house management asks you, “ Sir, He is wheezing a lot. Can I do a Chest x-ray and blood tests? Can I also start him on Salbutamol/adrenaline nebulizations, and IV steroids too?”
KUSH
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Bronchiolitis - Investigations
Bronchiolitis is a clinical diagnosis. Investigations contribute very little. CXR may be indicated in
severe respiratory distress or in case of a diagnostic uncertainty.
X-ray often reveals bilateral hyperinflation, findings like segmental atelectasis may be seen
some times Blood tests do not contribute.
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The resident doctor is very confused about the management of bronchiolitis. But he is not to be blamed, since there is so much controversy regarding the
role of various medications in bronchiolitis.
What is the rational management for Kush?
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Bronchiolitis - Management
Non Controversial Oxygen IV fluids
Controversial Adrenaline nebs Bronchodilators Steroids Antibiotics
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Bronchiolitis - Fluids Oral feeding,
if tolerated well, should be continued in infants with no more than moderate respiratory difficulty (respiratory rate < 80 breaths per minute, some chest-wall retraction, and maintaining an Spo2 > 92% in supplemental oxygen)
Intravenous fluids should be administered when there is moderate to
severe or severe respiratory difficulty (marked chest wall retraction, nasal flaring, expiratory grunting), marked tachypnoea (> 80 breaths per minute), apnoeic episodes, or visible tiring during feeds.
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Bronchiolitis - Fluids Considerable variation in the intravenous
hydration strategies recommended Normal general maintenance IV fluids are
used. Nasogastric tube feeding
Generally reserved for the recovery phase because: NG tubes blocks one nostril thereby increasing
the airway resistance and work of breathing. Feed in the stomach also compresses the
diaphgram and increases the risk of reflux and aspiration.
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Bronchiolitis – Oxygen
The use of supplemental oxygen therapy has not been subjected to randomized controlled clinical trials,
Use is considered appropriate to overcome hypoxemia.
In general, maintain an SpO2 ≥ 92% saturation
during the acute phase and during recovery, Can accept 90% to 92%SpO2, if the child is not
distressed and is feeding well.
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Bronchiolitis - Bronchodilators
There is no role for routine bronchodilators in bronchiolitis as they do not: improve oxygen saturation, affect rate or duration of hospitalization.
A trial of Nebulised bronchodilator can be given in: older infant (>6 months) with wheeze, with a
strong history of atopy, further therapy continued if there is a objective
improvement.
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Bronchiolitis - Steroids
Multiple studies have failed to demonstrate any clear efficacy of corticosteroids in viral bronchiolitis.
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Bronchiolitis - Adrenaline Very little support from randomized
clinical trials to the use of adrenaline in all children with moderate/severe bronchiolitis.
The improvement in respiratory symptoms across studies has been inconsistent and short lived.
May use Nebulised adrenaline as a potential rescue medication for those who are to be admitted.
Dose varies between 0.01ml/kg to 0.3ml/kg per dose of 1:1,000 solution.
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Bronchiolitis - Antibiotics
RCTs failed to demonstrate any benefit in hospitalized infants with bronchiolitis.
The only role for antibiotics is: complicated bronchiolitis where a secondary
bacterial infection is suspected. This is rare, but not easily excluded in a sick
infant with fever, toxicity and significant opacities on the chest radiograph.
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Bronchiolitis -sedation Sedatives should be avoided Irritability may be a sign of Hypoxia Sedatives can decrease the oxygenation as
well as give a false sense of relief No safe sedative Attempt to comfort the child as far as possible
Fever control Nasal clearing Feeding Non threatening manner of oxygenation/ nebulisation
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VIRAL BRONCHIOLITIS
Mild bronchiolitis• Normal ability to feed• Little/no resp. distressNot hypoxemic
Moderate bronchiolitis Moderate resp. distress Mild hypoxemia +/- brief
apnea +/- short of breath
Severe bronchiolitis Severe resp. distress +/-
apnoeic episodes +/-hypoxemic
Looking tired Can’t feed
Does not need investigations
Home treatment
Admit Humidified O2 to maintain
SaO2 above 92% IV fluids Observe for deterioration
Admit- ICU care O2 to maintain SaO2 above 92% IV fluids Cardio respiratory monitoring ABG, CXR Assess need for - ventilatory
support/ ICU care
Improvement• Decrease O2 [guided by SaO2]• Re-establish feeding• Discharge when distress
decreased and feeding well
DeteriorationTreat as severe bronchiolitis
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Kush was treated with IV fluids and oxygen supplementation. He improved with 3 days.
His mother now feels that he is comfortable and wants to take him home.
What would your opinion be? What would be your discharge
criteria for bronchiolitis?
Discharge criteria An infant is considered ready for discharge if
he or she had: Not received supplemental oxygen for 10 hours. Minimal or no chest retractions Feeding adequately without the need for IV
fluids.
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Parnami, 3 year old female Presents with an acute history of fever, cough
for 3 days She is irritable and has significant cough The parents are worried because the local
practitioner has told them that Parnami has pneumonia and should be admitted. They seek your opinion.
What will you look, hear or investigate to confirm the diagnosis?
The ball is in your court!
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Most consistent clinical sign of pneumonia
Age Respiratory rate (breaths/min)
< 2 months 60 or more
2 months upto 12 mo
50 or more
12 months upto 5 years
40 or more
WHO recommends using these Respiratory rate cutoffs to diagnose pneumonia
at the community level
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Parnami has a respiratory rate of 48/min
She has tachypnoea and a RR higher than the age specific cutoffs endorsed by WHO,
Dr Padma, your resident says “Does this mean she has pneumonia? This is simple and I can use this in my OPD screening too”.
Is she right?
Age Respiratory rate (breaths/min)
< 2 months 60 or more
2 months upto 12 months
50 or more
12 months upto 5 years
40 or more
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Tachypnoea
A sensitive and specific tool – 66% approx as good or better than auscultation for pneumonia
But there are several clinical situations which can cause rapid breathing e.g. Wheezing –asthma/bronchiolitis/WALRI
Non pulm causes like metabolic acidosis, CHF, raised ICT can also cause tachypnoea
A clinician must use this merely as a beginning step.
Use all clinical skills for making a final conclusion.
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Child with Cough, Rapid, Difficult breathing Consider Bronchiolitis-VAW if:
Age 1mo -1yr Presence of Upper respiratory catarrh Progressive increase in resp distress
(tachypnoea, retractions) Wheeze + crackles Clinical and radiological evidence of
hyperinflation
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Child with Cough, Rapid, Difficult breathing
Consider LTB-Croup if: Hoarseness of voice and barking/brassy
cough Stridor Mild to marked respiratory distress Sonorous rhonchi Fever usually mild or spiking (tracheitis,
rare)
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Child with Cough, Rapid, Difficult breathing Consider Asthma if:
Recurrent episode, 3 or more Wheeze Good response to bronchodilator Hyperinflation Family/personal history of atopy
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Can viral or bacterial pneumonia be clinically distinguished
Perhaps, No All of the following studied and not
found useful Presence of wheeze ESR CRP COUNTS CXR findings
Advantage of using the current methodology- decreases the confounder to viral pneum alone rather than broad ALRTI
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Dr Padma is now fully convinced. She says, “Now I know that simple clinical tools used judiciously can differentiate between different causes for cough and rapid breathing. And therefore help us be rational in management.”
But Sir, A. How do I confirm the
diagnosis? and if I have to use the correct antibiotics,
B. How can I suspect or confirm the probable organisms?”
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DIAGNOSIS RADIOLOGICAL
Do all patients require a chest radiograph?
NO, Not all CAP, particularly if on domiciliary
treatmentFew -Yes,
If complication suspected (for example, pleural effusion)
Ambiguous Clinical features
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MICROBIOLOGICAL
• Not recommended routinely• Takes a long time and hence has
limited utility• Sputum cultures / cough swabs have
relatively poor reliability• Invasive methods can not be justified
for routine pneumonias.
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Role of pulse oxymetry, acute phase reactants, etc. in pneumonia
Routine microbiological tests are of no use.
TLC, DLC, CRP are not diagnostic but may be useful to monitor the response to treatment.
Pulse oxymetry is a good tool for assessing the severity and for monitoring response in those with severe disease.
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QUESTIONS?????
In the absence of a microbiological diagnosis in most cases, How does one know which bacteria is the offending organism?
Are there any other supportive evidences for the probable etiology?
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Proportion of cases attributable to different etiological agents
2-60m age Viruses- 35% Bacteria- 60%
H influenzae Strep pneumo Staphylococci Mycoplasma – 24-30% More in above 5 years
Chlamydia- 6-11% Mixed infections- 9%
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0-3 months Gram Negative St pyogenesChlamydiaViruses
3mo-5yrs Str pneumoniaeH InfluenzaeStaph aureusVirusesMycoplasma pneum
>5 yrs Str pneumoniaeStaphylococcusVirusesMycoplasma pneumSt pyogenesH Influenzae
Age related Pathogens involved in Community Aq Pneumonia
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Defining Community Acquired Pneumonia
Community acquired pneumonia is an acute infection of the pulmonary parenchyma in a previously healthy child, acquired outside of a hospital setting. The patient should not have been hospitalized within 14 days prior to the onset of symptoms or has been hospitalized less than 4 days prior to onset of symptoms.
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What it excludes
Child with any immune-deficiency Severe Malnutrition Post measles state
Ventilator assoc Pneum Nosocomial spread Recurrent – which one??
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Reliability of predicting a special etiological agent based on clinical features and/or radiography
Generally POOR ONE EXCEPTION - STAPH
More likely if Very rapid progression Skin Lesions, infected scabies PE/ Pneumothorax/ empyema ?post measles
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Parnami
On detailed examination, she has tachypnoea, no cyanosis or diaphoresis. She is conscious but irritable.
She has significant lower chest retractions and flaring of the alae nasi.
How bad is she? How should she be treated?
The ball is in your court!
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Assessing severity
WHO classification useful Severe:
Tachypnoea with accessory muscles working Very Severe:
Tachypnoea with accessory muscles working AND
Altered sensorium, orCyanosis, orDifficulty in feeding, orPoor perfusion, etc
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Mild Severe
Infants
• Temperature < 38.50C RR < 50 breaths/min Mild recession Taking full feeds
• Temperature > 38.50C RR > 70 breaths/min Moderate to severe recession Nasal flaring Cyanosis Intermittent apnea Grunting respiration Not feeding
Older children • Temperature < 38.50C RR < 50 breaths/min Mild breathlessness No vomiting
• Temperature > 38.50C RR > 50 breaths/min Severe difficulty in breathing Nasal flaring Cyanosis Grunting respiration Signs of dehydration
Severity Assessment
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Indications for admission to hospital in infants: SaO2 < 92%, cyanosis respiratory rate > 70 beats /min and difficulty in breathing intermittent apnea, grunting not feeding; family not able to provide appropriate observation or
supervision. Indications for admission to hospital in older
children: SaO2 < 92%, cyanosis; respiratory rate > 50 breaths / min; difficulty in breathing grunting signs of dehydration family not able to provide appropriate observation or
supervision.
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Supportive therapy for CAP
Oxygen : as indicated by pulse oxymetry and/ or clinical signs of hypoxia like rapid breathing as well as
retractions
IV Fluids: If dehydrated, Tachypnoea severe enough to make the child unable to drink,
or impending respiratory failure.
Fever management Important as fever increase oxygen requirement Paracetamol and sponging are useful in most situations.
Bronchodilators, where indicated should be used to decrease the work of breathing.
Chest Physiotherapy helps in preventing atelectasis.
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Disease Pneumonia
Setting Domicilliary
AGE First Line Second Line Suspected Staphylococcal ds
Upto 3mo
Usually Severe, treated as inpatients
3mo- 5yrs of
age
Amoxycillin Co-amoxy clavulinic acidORChloremphenicol
CefuroximeOR
Co-amoxy clavulinic acid OR
Amoxycillin+ Cloxacillin*
5 yrs plus
Amoxycillin MacrolideORCo-amoxy-clavulinic acidORChloremphenicol
CefuroximeOR
Co-amoxy clavulinic acidOR
Amoxycillin+ Cloxacillin*
*Use Separately as combinations available are not scientific
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Severe – Very Severe PneumoniaTreat as In-patient
Age First Line Second Line
0-3 mo Inj 3rd Gen Cephalosporins:Cefotaxime/Ceftriaxone
+ Aminoglycoside (Gent/Amika)
Inj Co-amoxy clavulinic acid +
Aminoglycoside (Gent/Amika)
3mo-5 years Inj AmpicillinOR
Inj ChloremphenicolOR
Inj Ampicillin +Inj Chloremphenicol (<2 years of age)
ORInj Co-amoxyclavulinic acid
Inj Co-amoxy clavulinic acid OR
Inj 3rd Gen Cephalosporins:Cefotaxime/Ceftriaxone
5 years + Inj AmpicillinOR
Inj ChloremphenicolOR
Inj Co-amoxyclavulinic acidOR
Macrolides (if Mycoplasma suspected)
Inj Co-amoxy clavulinic acid OR
Inj 3rd Gen Cephalosporins:Cefotaxime/Ceftriaxone
ANDMacrolides
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Severe- Very Severe Disease
SUSPECTED STAPHYLOCOCCAL DS
Inj 3rd Gen Cephalosporins: Cefotaxime/Ceftriaxone
+ CloxacillinOR
Inj CefuroximeOR
Inj Co-amoxyclavulinic acid
Second line: Vancomycin/ Teicoplanin +
Inj 3rd Gen Cephalosporins
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Issues for severe disease
All parenteral drugs to begin with How Long? Step-down/ switch therapy
3rd generation oral like Cefopodoxime [NOT Cefixime]
Fluoroquinolones not recommended
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Duration of therapy
Domiciliary 5-7 days If admitted: Switch to oral after 48-72
hrs or earlier if can accept orally. Total 5-7 days
If on second line then IV for 7-10days If Staph.:
2 weeks if no complication; Else 4-6 weeks
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Parnami
While on treatment, Parnami deteriorates on 5th day of treatment
Her X-ray shows progression of her disease to the other lung as well.
She is very distressed, has irregular breathing and has cyanosis
Should she be shifted elsewhere?
The ball is in your court!
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INDICATIONS FOR TRANSFER TO PICU
Transfer to PICU should be considered when: failure to maintain SaO2 >92% in FiO2 >0.6 shock rising respiratory and pulse rates with
clinical evidence of severe respiratory distress and exhaustion with or without raised Paco2
recurrent apnea or slow irregular breathing.
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Does She have Nosocomial Pneumonia?
Possibilities are: Progression of Existing Disease,
Early Hospital Acquired Pneumonia
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Defining Hospital Aq Pneumonia
HAP - Hospital Aq Pneumonia Pneumonia that occurs 48 hours or more
after admission, which was not incubating at the time of
admission. Managed in a hospital ward or ICU as per
severity
VAP – Ventilator associated Pneumonia Pneumonia that arises more than 48–72
hours after endotracheal intubation
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Further definitions are needed Early-onset HAP and VAP,
defined as occurring within the first 4 days of hospitalization,
usually carry a better prognosis, and are more likely to be caused by antibiotic
sensitive bacteria.
Late-onset HAP and VAP (5 days or more) more likely to be caused by multidrug-resistant
(MDR) pathogens, associated with increased patient mortality and
morbidity.
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• Piperacillin tazobactam/ cefoperazone sulbactam with
an aminoglycoside or Fluoroquinolone• Add vancomycin/ linezolid if MRSA suspected
P. aeruginosaAcinetobacterMRSA
Nosocomial pneumonia after 4 days of hospitalization
• Ceftriaxone/ cefotaxime with a macrolide
S. pneumoniaeH. influenzaeS. aureusRespiratory
virusesMycoplasma
Nosocomial pneumonia in first 4 days of hospitalization
Treating Nosocomial Pneumonia
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Chelsea
4 yr female Fever 5 days, cough since 3days Pain chest, difficulty in breathing – 1 day
Febrile, RR 46/mt, no distress AE Rt side lower zone Diagnosed as pneumonia and put on
oral Amoxycillin
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Preliminary investigations
CBCHb 11.2, TLC 41,400, P 62 L17 band cells 7CXRRight Lower lobe pneumonia
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Case Contd.After 48 hrs, Fever persists. Develops increasing respiratory distress,
Chest pain. After 72 hrs,still no response.
What is the likely diagnosis?
Any other clinical information one needs?
What investigations should be ordered?
The ball is in your court!
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Question to the clinicianWhat is the likely diagnosis?
Complication Progression- non response Phlebitis Co-infection
Any other clinical information one needs? Any predisposing factor – immune suppression H/o Contact with TB case New Signs including Chest Signs
What investigations should be ordered? CBC, X-ray, Quantitative CRP(?)
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Chelsea
Rt Lower Lobe Pneumonia with effusion.
H/o Pyoderma, Measles,
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Further Investigations advised
Pleural tap- routine, gram stain Culture Latex agglutination test
Blood culture Ultrasonography
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Chelsea
Pleural fluid WBC 2400/cumm; 19% polys, 72% lymphos RBC 0.25 million Protein 4.9 gm% Sugar 25 mg% Gram stain: gram positive cocci, no AFB Latex negative C/s awaited
Blood culture awaited
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What is Empyema?
Presence of pus /micro organism in pleural fluid.
3 stages Exudative (24-72 hrs) Fibrino-purulent (7-10 days) Organizing (>10 days)
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What are the common bugs?
Streptococcus pneumoniae Staphylococcus H. influenzae Grp A Streptococcus Klebsiella Mycobacterium tuberculosis
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When to suspect Empyema?
Fever, chills, dyspnea, rapid breathing, chest pain, cough
No response to antibiotics/ worsening after 48 hrs of initiation in cases of pneumonia
Post measles state Co existing staphylococcal skin
infections, boils, arthritis, pyomyositis, etc
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How to confirm ?
Pleural Fluid AnalysisPurulent fluid pH<7.1, Glucose <40, Proteins>3g/dl, LDH>1000 IU/L
• X Rays USG- Size, site, loculations, adhesions
(Echoic) CT- Little role
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Recapitulating Chelsea’s results of investigations
Pleural fluid WBC 2400/cumm; 19% polys, 72% lymphos RBC 0.25 million Protein 4.9 gm% Sugar 25 mg% Gram stain: gram positive cocci, no AFB Latex negative C/s awaitedBlood culture awaited
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Question to the clinician????
Why is there is lymphocytic predominance if it is bacterial Empyema? Partially treated case
Can this be mycobacterial empyema ? Unlikely, short acute history, no
epidemiological clues
How should one manage this case?
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How to Treat?
Antibiotics WITH
Intercostal drainage (ICD) ICD plus Fibrinolytics Video assisted thoracic surgery (VATS) Open decortication Rib Resection/thoracoplasty/Lobectomy
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Antibiotics Co amoxyclav
or Cloxacillin with ceftriaxone If no response or resistance based on
cultures second line drugs>7 days. Vancomycin / Teicoplanin, Linezolid plus
ceftazidime. Duration
I.V till afebrile/removal of tube usually 7-14 day Total for 4-6 wks
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4.
Escherichia coli and Klebsiella
4.
Cefotaxime as in A 2.a
5.
Pseudomonas
5.
a.
Ticarcillin 200-300 mg/kg in 4-6 doses or
b.
Ceftazidime 125-150 mg/kg in 3 doses with
c.
Tobramycin 5-7 mg/kg in 3 doses.
B.
Anaerobic bacteria
1.
B. fragilis
1.
Clindamycin 24-40 mg/kg in 3-4 doses
2.
All except B. fragilis
2.
a.
Same as B.1 or
b.
Penicillin G as in A 3
•Insertion of a chest tube: the site is selected in the mid-axillary line in the 5th intercostal space on the superior aspect of the 6th rib in the “safe triangle”
Ultrasonographically guided insertion found to be effective.
•May Seek help from pediatric surgeon.
Forgotten art
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Post tube –thoracotomy care
Keep the system patent.
Keep the system airtight.
Maintain sterility of the system to avoid
introducing bacteria into the intrapleural space.
Drain should be clamped for 1 hour once 10
ml/kg are initially removed
Dependent drainage
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Patients should perform as much activity
as can be tolerated.
Encourage the facilitation of deep
breathing and airway clearance.
Use analgesics on an individual basis to
facilitate airway clearance.
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Do not do this.
.
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When to remove ?Timing of elective removal essentially a clinical
decision Amount of fluid draining No Bubbling Child’s temperature General well being CXR and USG appearance Fall in acute phase reactants. (BTS Guidelines, Thorax
2005)
It is not necessary to wait for complete cessation of drainage- accept small drainages like upto 30-50ml/day. But no air leak should be there.
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What is the role of Fibrinolytics ?
Streptokinase, Urokinase, Alteplase Recommended by some for a shorter stay in
hospital Complicated parapneumonic effusion (thick fluid
with loculation). No evidence that any of the three is more
effective Mainly in UK, studied in a randomized controlled
trial in children so is recommended by BTS. UK :40.000 U in 40 ml NS > 10 kg
10,000 U in 10 ml NS < 10 Kg. 4 Hrs Dwell time needed
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ComplicationsHemorrhage
Fever
Pleural pain
Arthralgia
Headache
Hypoxemic resp failure
Anaphylaxis
Antigenic response (streptokinase)
UK adhesion VATS difficult.
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Surgery – when and what?
Failure of treatment and collection of fluid >10 days
Modalities VATS Open thoracotomy and debridement Mini Thoracotomy and debridement
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Video assisted Thoracoscopy
Primary /secondary• Primary VATS if patient presents late (>7 days
history) or if there are loculations on imaging studies
Secondary VATS when std therapy fails.
Advantages• Early recovery & resolution of empyema
comparable to open decortication. • A viable solution, decreases the stay but not
easily available and not as cheap
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Long term outcome - Conservative treatment
Satish et al: Decortication and ICT drain no
difference on long term outcome
Pleural thickening has a benign course and
capacity to resolve better in children due to
inherent elasticity of both thoracic cage and lung
tissue.
Patients tested had lung function
between 80% to 100% of predicted Satish et al. Arch Dis Child 2003 Satpathy et al. I J Ped 2005
Recurrent Pneumonia
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Amit is a 3 year old who is brought for fever and a rapid respiratory rate since 3 days.
On examination he has a grunt and a respiratory rate of 44/min.
On auscultation he has an increased vocal resonance in the right mammary and infra mammary area.
Diagnosis ?
What are your thoughts? The ball is in your court!
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His X ray shows……
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Amit contd….
‘ Not again ‘ says his mother. He had a pneumonia three months ago . Here are his X rays ……….
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Recurrent pneumonia
‘ At least two episodes of pneumonia occurring in one year or three episodes over any period of time.’
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Amit’s story contd…
“Dr, last time it was in the left lung and now it is in the right lung. Is it part of the same problem?”
Any comments?
The ball is in your court!
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Key message
Recurrent Pneumonia is a symptomsymptom of an underlying disease and not a diagnosis in itself .
Causes include Commonest-
Asthma, Aspiration syndromes Less common-
Congenital anomalies, FB, CVS shunts, TB, tumors Not infrequent
CF, Immunodeficiencies, ciliary dyskinesias
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Key points on history Age at onset/ First documented pneumonia Delayed cord fall History suggestive of aspiration or setting
for aspiration (choking, nasal regurgitation, recurrent seizures, dysphagia)
Temporal relation of cough to feeding or posture
Family / personal history of atopy, nocturnal cough, bronchodilator relief
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Key points on history contd..
Choking while eating a nut or similar object in the past
Consanguinity Family History Multiple multifocal infections e.g. diarrheas ,
pyoderma, ear infections Malabsorptive stools Contact history
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Key points on examination.
Oropharyngeal examination Clubbing Other features of atopy e.g. flexural
dermatitis Failure to thrive, BCG scar, tonsil size Pallor, generalized adenopathy Perforative otitis media Cardiovascular system Respiratory system
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How should one approach Amit’s problem?
Are the past symptoms both upper and lower respiratory or only lower respiratory ?
Same lobe at every episode or different lobes?
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Key message
Upper and lower respiratory Asthma Immunodeficiency Ciliary's dyskinesia CF
Only lower respiratory Aspiration
syndromes Congenital
anomalies CVS shunts FB TB Tumors
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Recurrent Pneumonia
SAME LOBE Foreign body Tuberculosis Congenital
Anomaly
DIFFERENT LOBES
Aspiration Asthma CVS shunt Mucociliary defects
Immunodeficiencie
s
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Amit
Amit has had several episodes of otitis media, diarrhea and recurrent pneumonia in different lobes
He tends to get sudden severe infections at various sites, which need intense antibiotic treatment
On Investigation is found to have primary immune deficiency :Agammaglobulinemia
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Cough with expectoration: likely possibilities
Bronchiectasis (Long standing history) Lung abscess (Relatively shorter
history) Bronchitis (More commonly seen in
adults)
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Payal a 8 year old girlpresented with persistent cough and expectoration with intermittent increase in the symptoms. She requires a course of antibiotics each time.
X ray film of payal
1. What are likely possibilities?
2. What all questions should be asked to ascertain the diagnosis?
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Suspected suppurative lung disease: Ask
Past history of pneumonia, pertussis, measles, foreign body inhalation and tuberculosis (Post infectious bronchiectasis)
Infection in other parts of body (Immune deficiencies)
Family history of similar illness, sib death (Immune deficiency, cystic fibrosis, primary ciliary dyskinesia)
History of mal-absorption and failure to thrive (Cystic fibrosis)
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Suspected suppurative lung disease: look for
Respiratory difficulty: RR, chest indrawing, accessory muscles
Clubbing and crepitations
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Payal gave history of onset of illness since early infancy, she was passing stools very frequently, her stools were foul smelling and bulky, despite good appetite she was not growing well.
There was family history of sib death who did not pass stool at birth and died after 3 days
She had cystic fibrosis: confirmed by sweat test and mutation analysis.
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Investigations for bronchiectasis
Radiology Findings on X-ray of chest findings are
nonspecific. Look for the following in the lung parenchyma: ring like densities with clear centre parallel linear lines mimicking rail track irregular ill-defined vascular markings or unequal aeration due to atelectasis and
hyperinflation X-ray of para nasal sinuses picks up
associated sinusitis in few cases.
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Investigations for bronchiectasis
High resolution computerized tomographic scan (HRCT) of chest: Very sensitive and non invasive method The findings include
air fluid levels in the distorted bronchi linear non tapering airways distended bronchi in periphery and thickened bronchial walls
Microbiological Studies Sputum culture/ bronchoalveolar lavage may be tested. Isolates and their sensitivity will help in selection of
antibiotics.
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Causes of bronchiectasis
CONGENITAL ACQUIRED Gross structural defects
o Tracheomegaly
o Bronchomalacia
o Pulmonary sequestration
Ultrastructural defects
o Primary ciliary dyskinesia
Metabolic defects
o Cystic fibrosis
o Alfa-1-antytrypsin
deficiency Immunodeficiency
o Hypo-gammalobulinemia
Infections o Pneumoniao Measles o Tuberculosis
Obstructiono Foreign bodyo Enlarged node
Disorders of immunity/ Allergyo Allergic broncho- pulmonary Aspergillosis
(ABPA) o Autoimmune disease
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Investigations for bronchiectasis
Pulmonary function tests Further Investigations are indicated for the
underlying cause. The cause remains unknown in 30-50 % of patients. Needed investigations are :
F O Bronchoscopy, HRCT or bronchography, serum immunoglobulin levels, Gastro esophageal reflux studies, tests for tuberculosis and fungal infections studies for ABPA Sweat chloride, and Ciliary's studies
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Begin general measures (Antibiotics, physiotherapy, adequate nutrition)
Presumptive diagnosis(Based on clinical features and radiographic changes)
Etiology found No etiology found
Institute specific therapy as indicated Continue general measures
Continue general measures
Etiologic evaluation
Close follow up
Improvement/ Stabilization No improvement/Deterioration/Frequent exacerbations
Chest CT/Bronchography Continue general measures Periodic monitoring
Resectable Lesion SURGERY
Lesion non-resectableAggressive medical
therapy
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General Measures Antibiotic therapy:
Choice of antibiotic depends on the isolates Most exacerbations are caused by the bacteria
colonizing the diseased airway Empirical therapy :
Co-amoxyclav/ Ceftriaxone + ciprofloxacin (particularly in those with
pseudomonal colonization). Airway Clearing:
Very important tool, but underused promote bronchial hygiene improve breathing efficiency promote physical reconditioning
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Jatin presented with fever, chest pain, expectoration: 6 weeks
Did not respond to broad spectrum antibiotics
He had mild clubbing, bronchial breathing right infrascapular region and crepitations all over right side of chest
The ball is in your court!
What are the diagnostic possibilities?
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Causes of lung abscess Most frequently a complication of bacterial
pneumonia especially those due to Staphylococcus aureus, Klebsiella pneumonia and Pseudomonas.
May develop in sequestration of lung tissue or in association with foreign bodies, bronchial cysts or stenosis.
Staphylococcal lungs abscess are often multiple, while those complicating aspiration are solitary.
May rupture into the pleural space leading to Pyopnuemothrax
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Antibiotics Used
Lung abscess (from community) S. aureus K. pneumoniae P. aeruginosa
Cefotaxime/ ceftriaxone and Cloxacillin
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CONCLUSIONS Viral infections and non infectious causes of
cough do not need antibiotic therapy. Few situations for empiric use of antibiotics
and Unwarranted use does not prevent a
subsequent secondary infection in most situations.
First line antibiotics are still effective and drugs of choice
Newer 3rd - 4 th generation Antibiotics should be reserved for few non responders.
All non responders are not due to a resistant bug. Other causes are as important.
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CREDITS RTI GEM Varinder Singh (Team Leader)
Mahesh Babu R J Chinappa
G Ghosh S K Kabra
Indu Khosla Raju P Khubchandani
Tanu Singhal(alphabetic order)
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Sponsored Through Educational Grant by
Cipla
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THANK YOU FOR YOUR KIND ATTENTION