pediatric pulmonary case conference
DESCRIPTION
Pediatric Pulmonary Case Conference. Sunil Kamath MD Post-Doctoral Fellow Childrens Hospital Los Angeles. HPI. 6 month old male with no significant PMH 3/17 cough, rhinorrhea, nasal congestion, Fever 101 cranky and NBNB emesis x 1 3/18 "moaning" while breathing - PowerPoint PPT PresentationTRANSCRIPT
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Sunil Kamath MDPost-Doctoral Fellow
Childrens Hospital Los Angeles
Pediatric Pulmonary Case Conference
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HPI
6 month old male with no significant PMH3/17
cough, rhinorrhea, nasal congestion, Fever 101cranky and NBNB emesis x 1
3/18 "moaning" while breathingPMD diagnosed a URI and pt. was sent homedeveloped subcostal retractions and taken to outside ED
where he received breathing treatments, improved, and was discharged home
3/19Irritable and had subcostal retractionsReturned to outside ED
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ED Course
Persistent retractions and pale
SpO2 71% placed on O2 “pinked up”
Received continuous aerosol treatments
Transferred to outside hospital PICU for further care with
the presumptive diagnosis of bronchiolitis
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FT, NSVD, no complications, home on DOL 2Surgical history: noneNKDAImmunizations: has not received 6 month
vaccinationsDiet: Enfamil 6oz TID, baby foodsFamily History: father with bronchitis as a childSocial History: Lives with mother, father and 2
yo sister, no tobacco exposure, no petsAll other ROS negative
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Outside Hospital Physical ExamVS:
Temp: 36.7 CHR: 174 bpmRR: 53 breaths per minuteBP: 98/67 mmHgSpO2: 98% on 1.5 LPM via NC
PE:General: Awake in mild/moderate respiratory distress with
subcostal retractionsResp: Coarse breath sounds bilaterally. + Rhonchi. No
Wheezing.Heart: RRR. Normal S1 and S2
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Labs
18.3 \ 10.7 / 334
/ 36 \ 149 107 8 149 Ca:9.8
5.1 21 0.4Respiratory culture – Negative for bacteriaRSV DAA – negativeInfluenza DAA – negativeTotal IgG, IgA, IgM, IgE – normalCXR
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Outside Hospital Course3/20 Intubated for worsening respiratory distress HFOV x 1
weekStarted on ABX and steroids
3/25 ETT viral culture: Adenovirus (not typed)3/30 DVT of right leg Rx Lovenox4/11Extubated to HFNC and steroids were weanedDeveloped wheezing, prolonged expiratory phase, increasing
distress IV steroids were re-started and patient improved5/4 Changed to Prednisone 5mg BID and transferred to the floor 5/5 MSSA bacteremia Rx oxacillin5/6 Developed increased tachypnea with nasal flaring and
fatigue during feeding5/6 Chest CT
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consolidation of RLL and LUL with associated cylindrical bronchiectasis
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5/7 Transferred to CHLAVS
Temp: 37.9 deg CHR: 148 bpmRR: 38 Breaths/MinBP: 144/90 mm HgSpO2: 99% on ½ LPM
PEGeneral Appearance: laying in bed, moderate respiratory
distress, becomes fearful with examChest: symmetric chest rise, subcostal retractionsRespiratory: diffuse crackles, wheezing, forceful expiration
with gruntingCardiovascular: RRR, no m/r/g, 2+ pulses
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Labs18.72 \ 11.5 / 557
/ 35.9 \ Segs 44, Bands 0, Lymph 42, Mono 13, Baso 0, Eos 1
139 97 11 123 Ca:9.9
5 32 0.2
CBG: 7.46/50//36
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“The lungs are hyperinflated. There is streaky perihilar disease with peribronchial thickening bilaterally.”
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What is your assessment and plan?
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Hospital CoursePlan: chest CT, bronchoscopy, lung biopsy, and iPFT when
stable5/10 SCINTI: normal5/11 ECHO
Small secundum atrial septal defect vs. patent foramen ovale.No evidence of PHTN
5/13 MBSS: normal5/18 Wheezing. Prolonged expiratory phase. Increasing
respiratory distress. Prednisone Solumederol5/21 Admitted to the PICU for stabilization and repeat CT
scan5/24 RV panel: negativeImmunology workup: unremarkable
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Template
progression of bronchiectasis and scattered areas of groundglass opacity
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What is your management plan?
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Management
Bronchiolitis Obliterans:Azithromycin (5mg/kg QMWF)Methotrexate (10-15mg/m2/dose SQ Qwk)Continued IV steroids
5/25 Developed thick secretions and was difficult to ventilateEmpirically started on Vanc and ZosynTrach cult (Many Haemophilus influenzae, Beta lactamase
negative) Ceftriaxone
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PICUadmit
Intubated
Azithro
MTX
Extubated
ABX started
IV steroids
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Bronchiolitis Obliterans
Rare form of chronic obstructive lung disease that occurs after an insult to the lower respiratory tract
Etiology:
Bronchiolitis Obliterans in Children. Pediatric Pulmonology 39:193-208 (2005)
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Pathophsiology:Inflammation and fibrosis of the terminal and
respiratory bronchioles narrowing and/or complete obliteration of the airway lumen
Bronchiolitis Obliterans in Children. Pediatric Pulmonology 39:193-208 (2005)
Kumar: Robbins and Cotran Pathologic Basis of Disease, Professional Edition , 8th ed.
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Diagnosis:CXRPFTBronchoscopy - neutrophilia HRCT: mosaic patternOpen lung biopsy:
Sampling error due to patchy airway involvement 2 categories:
proliferative bronchiolitis (intraluminal polyps) constrictive bronchiolitis (peribronchiolar fibrosis)
TreatmentSupportive careSteroidsImmune modulators
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Thank You